News From ACFAS

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Looking to become more involved with ACFAS and the advancement of the profession or know someone who may be? Consider becoming a member of the ACFAS Board of Directors.

Nominations are now being accepted for two three-year director terms on the Board. ACFAS Fellows who meet criteria for election are encouraged to submit a nomination application to Executive Director Chris Mahaffey by an extended deadline of September 4. The Nominating Committee will announce recommended candidates to the membership no later than October 5. Candidate information and ballots will be e-mailed to all voting members no later than November 29. Electronic voting will end on December 29. New officers and directors will take office during the ACFAS 2013 Annual Scientific Conference set for February 11-14, 2013, in Las Vegas.

For complete details on the recommended criteria for candidates and the nomination application, visit acfas.org/nominations, or contact Chris Mahaffey at 773-693-9300 or mahaffey@acfas.org. Questions regarding eligibility criteria should be directed to Nominating Committee Chair Glenn M. Weinraub, DPM, FACFAS, at 510-248-3039 or gweinraub@gmail.com. Register for and attend one or both of these highly interactive and challenging programs. Reinforce your skills as you maneuver around surgical complications of the foot and ankle in the upcoming, hands-on surgical skills courses. Follow the links to register. Login is required:

• Surgical Solutions for Complications of the Forefoot, Friday, Nov. 2
• Surgical Solutions for Complications of the Rearfoot and Ankle, Saturday, Nov. 3

Faculty members will guide you through patient evaluation and the latest approaches and surgical techniques in a series of didactic lectures, demonstrations and the surgical skills laboratory. As you work together in the lab, your faculty will share critical insights gained through their extensive experience. There will be additional time for panel discussions and case presentations.

For more details on these events, download the full brochure and flip to pages 5 and 6.

Register now for the Surgical Solutions for Complications of the Forefoot, Rearfoot and Ankle series! Attend one of four Advances in Forefoot Surgery Workshops & Seminars. Want to learn cutting-edge techniques that will strengthen your surgical skills and enhance your current knowledge? These are close to home, hands-on opportunities that the College and four convenient ACFAS Divisions partnered to provide for practicing and in-training surgeons. Locations include Denver; Louisville, Ky.; Southfield, Mich.; and Charlotte, N.C. Check the educational calendar for dates and registration details.

Each program will begin on a 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.

For more information, download the full brochure here. In addition to acfas.org, ACFAS also has a patient education website, FootHealthFacts.org. We keep it updated with all the latest information on foot and ankle injuries, relevant articles and press releases, an interactive foot tool and a built-in “Find a Physician” column.

Through FootHealthFacts.org, consumers are guided through easy-to-use steps that lead them to finding the information they need on foot and ankle injuries, treatments and specialist surgeons in their area so they can meet you and potentially become your next patient.

Check it out for yourself, and encourage those you know to visit the website. You might just find there are people nearby with foot and ankle problems they never realized they had.

Foot and Ankle Surgery

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A randomized controlled trial was held to test whether autologous blood injection effectively alleviated Achilles tendinopathy symptoms in conjunction with standard management of the condition. The trial involved 33 patients whose average age was 50 years, with 40 cases of Achilles tendinopathy of median duration of 11 months. Participants were randomly assigned to solely receive standard treatment consisting of eccentric-loading exercises, or standard treatment plus blind peritendinous autologous blood injection, for 12 weeks. The researchers observed improvements in the Victorian Institute of Sport Assessment for Achilles (VISA-A) score of 7.7 units and 8.7 units in the treatment and control groups, respectively, at six weeks relative to baseline, with no clear effect of blood injection. VISA-A score improved to 18.9 units in the treatment group at 12 weeks, while the control group's score was unchanged. There were no identifiable cofounder. Only notable side effect with an incidence of 21 percent was postinjection flare.


The complexity of displaced intra-articular calcaneal fractures as well as the various treatment options make this type of injury a therapeutic challenge, and the most common minimally invasive method is closed reduction of fracture and percutaneous cannulated screws fixation. A study was held to assess the medium-term results of a new percutaneous treatment technique in 60 cases between 2007 and 2009. The method involves application of the principle of closed manipulation with a new reduction technique that manipulates the fragments with a medial subperiosteal tunnel. Furthermore, the procedure also entails a new screw distribution method to fix the fracture. About 38 percent of all cases had an excellent outcome, 41 percent had good results, 15 percent had fair results and 5 percent had poor results, according to the AOFAS Hind Foot Score. Overall satisfactory outcomes were 79.3 percent.


A study was conducted to compare 3T and 7T signal-to-noise and contrast-to noise ratios of magnetic resonance imaging clinical sequences for imaging of the ankles with optimized sequences and dedicated coils. Ten healthy participants were examined consecutively on both systems with T1-weighted 3D gradient echo (GRE), PD-weighted 2D fast spin-echo (SE) and T1-weighted 2D spin-echo (TSE). The signal-to-noise ratio (SNR) was estimated for cartilage, bone, muscle, synovial fluid, Achilles tendon and Kager's fat-pad regions. Contrast-to-noise ratio (CNR) was calculated for cartilage/bone, cartilage/fluid, cartilage/muscle and muscle/fat-pad, and compared by a one-way ANOVA test for repeated measures. Average SNR substantially increased at 7T versus 3T for 3D GRE; 2D TSE was 60.9 percent and 86.7 percent, respectively. A mean SNR decrease of nearly 25 percent was seen in the 2D SE sequence. A CNR gain was observed in 2D TSE images and in the majority of 3D GRE images.

Practice Management

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Dixon Davis, vice president of practice management at AAPC, a company that trains and provides credentials in documentation and coding audits, regulatory compliance and physician practice management, cites six basic steps medical practice managers can follow to realize financial success, starting with maintenance of productivity through effective monitoring. Managers also should always seek ways to augment revenue streams through the establishment of more efficient processes and additional services. All charges should be captured, first by ensuring that every service performed is identified on the billing sheet or in the electronic health record. Documentation and coding of the performed services must then be vetted for accuracy, and the information has to be submitted in a timely fashion.

The third step is the verification that correct insurance information, demographics and code entry are being submitted the first time. All processes involved with gathering this information must be carefully reviewed, and making sure it is right the first time must be prioritized. Achieving this requires clearly stated processes and expectations followed up with periodic audits to recognize areas of improvement. The fourth step involves effectively collecting patient balances, such as co-pays, deductibles, co-insurance or past due balances, while the patient is in the office. Practice managers must set a clear policy on what is expected, train the office staff on how to be effective and establish a culture where patients are held accountable.

The next step is to ensure that the billing office is working effectively. Billing departments must possess clearly articulated collection policies/processes that include how to handle denials, following up on aging claims, how and when to collect from patients, when to submit claims to collections and when to write off bad debt. The practice manager should take time to identify processes that are as simple and straightforward as possible, and then supply solid education and training so that the staff knows how to be effective in their duties. The last step requires periodic audits of contracted payer rates and operational expenses. By reviewing the former, the practice ensures that it is negotiating the best rates available so it can maximize revenue opportunities. Reviewing costs such as liability insurance, supplies, phone contracts and other operational costs helps guarantee that the practice is receiving the best available prices.


Insurers and health systems are increasingly offering case managers to work at independent practices as a cost-cutting measure within accountable care organizations or patient-centered medical homes, and there are issues to consider before accepting a case manager. Good alignment with the case manager can lead to enhanced patient care and the earning of bonuses for the practice, while poor alignment can lead to a waste of investment. Case management experts say the first issue worth contemplating is whether the practice has sufficient numbers of qualifying patients to keep the case manager busy. Case managers employed by an insurer typically are limited to handling patients on that company's plans, while a health system may wish to concentrate case management initiatives on patients with certain medical conditions to reduce care costs and qualify for shared savings bonuses from Medicare or commercial insurers.

If the practice has enough patients to satisfy that criterion, the next issue to consider is what the case manager's responsibilities will be and how they fit with the vision, mission and values of the practice. Responsibilities for the case manager can be diverse, but they should be specified in any contract covering the arrangement. These duties may include assisting patients with transportation requirements, encouraging them to improve diet and physical activity and managing migration from the inpatient to the primary care environment. The case manager also may aid patients' navigation of specialty care and access to preventive services, but whatever the arrangement, it must align comfortably with the physician and other practice members.

Another major issue concerns the degree of control the practice has over the case manager's work. Embedded case managers are not given free reign, even though they are not employed by the practice. A practice should have a say in case managers' work, and have the option of interviewing the individual much like a potential employee and stop working with him or her where appropriate. The contract should clearly communicate such issues. In the event a practice rejects the offer of a case manager from an outside entity, the insurer or health system may supply the funds to hire one. Although such an arrangement may have fewer strictures, it presents to practices the challenge of hiring and directly supervising the case manager.


Physician productivity is key to ensuring that a physician's practice is profitable, but for specialist physicians, much of their business hinges on referrals from other physicians, which means the key is to have a strong referral system that supports a busy and productive office. Many specialist groups starting new practices or trying to expand an existing practice spend time and money "marketing" their practices through newspaper articles, ads in local papers or magazines, flyers, pamphlets, radio ads and other traditional advertising methods, but these efforts are largely ineffective. For a practice that depends of referrals from other providers, the target market is providers and providers' staff, who make referrals on a few key perceptions. These factors include the clinical expertise of the specialist, the ease of making a referral and getting an appointment for a patient, the quality of feedback the specialist provides for them and whether the specialist accepts a patient's insurance.

Specialists should play a personal role in developing these key relationships, which running traditional ads will not accomplish. They need to personally put in time and effort to making connections with physicians. The first step is providing quality healthcare for every single patient. Offer personal visits by the specialist to the office of the referring physician to ensure clear communication. The referring office needs to know who you are and how you can help their patients. Treat referring offices as customers, and work with providers and staff to ensure an efficient referral process. Make it easy to refer to your office through a "VIP" treatment that will improve the likelihood of providers choosing your office. Get on as many payer panels as possible, and provide clear communication to referring providers' offices on what insurances you take. If a referring office has to spend time figuring out who they can refer to you, referrals will be less likely. Develop clear and concise reports to send back to providers, along with a policy to make direct contact whenever possible. Primary-care providers value feedback that is timely and informative. After developing a relationship, strengthen it with regular communication. Additional visits by a staff representing the specialist can be effective, but it is important for the specialist to stay involved in the relationship.

Health Policy and Reimbursement

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A bipartisan measure introduced in Congress would expand the number of Medicare-sponsored training slots for new doctors by 15,000. The bill, the Physician Shortage Reduction and Graduate Medical Education Accountability and Transparency Act (HR 6352), is sponsored by Reps. Aaron Schock (R-Ill.) and Allyson Schwartz (D-Pa.). Medical schools have been expanding their enrollments and new schools have been opening up as concerns have grown about a shortage that could reach more than 90,000 physicians by 2020, according to the Association of American Medical Colleges (AAMC). The legislation would produce 4,000 more doctors per year, about a third of the estimated number needed to avert a shortage, according to the AAMC. It would also establish measures to show how well residency programs meet a number of objectives, including training doctors in a variety of both in-patient and out-patient settings, using health-information technology and working in interdisciplinary teams.


New financial transaction rules for hospitals and other HIPAA-covered providers issued by the Centers for Medicare and Medicaid Services are expected to save as much as $4.5 billion over a decade, and by Jan. 1, 2014, providers must comply with an interim final rule obligating them to set up new operating standards for electronic fund transfers (EFTs) in healthcare as well as for describing adjustments to claim payments. The rule specifies that insurers offer a standardized, online enrollment for EFT and electronic remittance advice (ERA) to encourage more providers to enroll and receive electronic payments from multiple health plans; health plans also are required to send the EFT within a certain number of days of the ERAs so that providers can reconcile their accounts faster. Department of Health and Human Services Secretary Kathleen Sebelius says the new rules "will cut red tape, save money and ensure doctors spend more time seeing patients and less time filling out forms." Providers must comply with the interim final rule by Jan. 1, 2014.


The federal Health IT Policy Committee panel has received a draft of criteria that hospitals and physicians would need to meet to qualify for the third round of federal meaningful-use incentive payments. The draft was presented by the committee's meaningful-use work group. The recommendations included many new proposed criteria. Several fell under the broad category of improving care quality, safety and efficiency and reducing health disparities. Included was a recommendation to use the computerized provider order-entry function on electronic health-record systems for referrals and transition-of-care orders. The work group also recommended that eligible hospitals produce an electronic version of a "timely (within four days) transition document" when a patient transitions between care sites. More information can be found here.

Medicine, Drugs and Devices

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A "spray-on skin" which coats a wound with a layer of skin cells could help healing, researchers reported online Aug. 3 in the journal Lancet. HP802-247, developed by Healthpoint Biotherapeutics, is spray-applied cell therapy containing growth-arrested allogeneic neonatal keratinocytes and fibroblasts. The spray was tested on 228 people with leg ulcers. The findings showed that ulcers treated with the spray were more likely to heal and did so more quickly. Experts said faster healing could save money despite the cost of the spray.


Researchers may have discovered a way to prevent the onset of allopurinol hypersensitivity syndrome (AHS) in people who are taking allopurinal to treat gout. Researchers examined 54 cases of people with gout who developed AHS between January 1998 and September 2010 and found that the risk of developing AHS correlated with an increase in the size of the allopurinal starting dose corrected for estimated glomerular filtration rate. These and other findings led researchers to conclude that AHS could largely be prevented by keying the starting dose of allopurinol to kidney function and slowly ramping it up to therapeutic levels once it becomes certain that the patient can tolerate the drug.


A simple urine test before a woman reaches menopause may predict her risk of bone fracture. Researchers report that levels of a substance called cross-linked N-telopeptide of Type 1 collagen, or NTX, can predict the risk for future fracture in premenopausal, asymptomatic women. NTX is released into the urine when bones weaken. In a prospective analysis published online in the journal Menopause, the scientists studied 2,305 healthy premenopausal women ages 42 to 52, measuring NTX at the start of the study and following them for an average of seven years. During that period, 184 of them suffered at least one fracture. After controlling for age, weight, race and other factors, they found that women with a baseline NTX above the median were 59% more likely to have a fracture than those whose level was below the median.