News From ACFAS

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Want to learn the latest approaches and surgical techniques in an intensive and interactive state-of-the-art environment? Wish you could talk directly with expert faculty members who understand the challenges that rearfoot reconstruction and foot and ankle trauma present? Then join ACFAS this fall for two weekend surgical skills courses: Comprehensive Rearfoot Reconstruction (October 24–25, 2014; Jersey City, NJ) and Trauma of the Foot and Ankle (November 8–9, 2014; Aurora, CO, 15 minutes from Denver International Airport). Not only will you sharpen your skills and get your questions answered, you’ll spend 80 percent of your course time working in a hands-on surgical laboratory.

Both courses will feature a fireside chat with faculty and your fellow attendees with dinner. Use this time to share your cases (you can bring radiographs of your cases on a USB flash drive or CD), exchange ideas and best practices and gain knowledge and insight in an open and informal setting.

Visit acfas.org/skills to register for these courses today. Interested in exhibiting at ACFAS 2015 or know someone who may be? Exhibition and sponsorship opportunities are now available for the February 2015 conference in Phoenix. Join us and be one of the companies who exhibit in more than 100,000 square feet of exhibit hall space at our conference and reap the benefits of connecting and engaging with 1,300+ attendees who eagerly want to learn more about your unique products and services.

To reserve your booth or for more information on promotional/marketing and sponsorship opportunities, look for your Exhibitor Prospectus in the mail or view it online at acfas.org/phoenix. Congratulations to the Class of 2014! Did you know that all first-year podiatric surgical residents receive a complimentary first-year membership to ACFAS thanks to the support of the Regional Divisions? As a resident member, you not only have your dues for the first year waived (a $118 savings), but you also receive all cost-benefits of membership, including member pricing on conferences, products and services.

Kick-start your career with ACFAS! We connect residents to a community of your peers—the best and brightest foot and ankle surgeons in the country. You will also have access to the College’s premier website and access to the prestigious Journal of Foot & Ankle Surgery (JFAS) through the new JFAS iPad app—a must-have to increase your knowledge of the latest surgical techniques and research.

Applications for membership are available through acfas.org; joining now will provide an additional two months of membership, through September 2015—and will put JFAS in your mailbox that much sooner!

Once again, congratulations to the Class of 2014. The ACFAS Regional Divisions look forward to welcoming you to the College.

Foot and Ankle Surgery

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Using a headless compression screw during medial malleolus fixation can be a good alternative to the use of a partially threaded screw and/or Kirschner wire fixation, both of which can result in non-union rates as high as 20 percent as well as pain caused by prominent hardware, a new study has concluded. The study's authors examined records on 64 ankles that were corrected with headless compression screws, 44 of which had adequate follow-up for additional evaluation. The study found that patients who underwent medial malleolus fixation using headless compression screws experienced good clinical outcomes. Only one patient required hardware removal as a result of cellulitis, while one patient experienced delayed union. That patient's fracture later healed without further intervention. None of the patients experienced non-union, and none had to have the headless compression screws removed from their ankles due to painful hardware. In addition, the study found that the screws effectively compressed medial malleolus fractures. However, 10 patients experienced mild discomfort as a result of palpation over the medial malleolus.


A new study recommends the use of a modified Stainsby procedure to correct fixed claw toe deformities, as patients who undergo this procedure generally have favorable outcomes. The study involved 37 patients who underwent the Stainsby procedure using a modified extensor tenotomy step, which the study's authors said would make the technique safer, easier and faster to perform. Patients underwent follow-up at an average of 17 months, at which point they were interviewed and examined. The study's participants displayed significant improvements in a variety of endpoints, including metatarsalgia, callosity and requirement for insoles. In addition, median post-operative American Orthopaedic Foot and Ankle Society (AOFAS) forefoot scores and Foot and Ankle Outcome Scores all compared favorably to previously reported scores. Although the study's authors said their findings supported the use of modified Stainsby procedure, they also noted that their research had several limitations, including the length of the follow-up period and the lack of pre-operative clinical scores that could be used for comparison purposes.


For the first time, orthopaedic surgeons have performed a study that compared the results of repeat arthroscopy and osteochondral autologous transplantation (OAT) following failed primary arthroscopic treatment in patients with osteochondral lesions of the talus (OLT). After following up with 44 patients who underwent OAT (Group A) or repeat arthroscopy (Group B) following failed primary arthroscopic treatment, the surgeons concluded that OAT was significantly superior to repeat arthroscopy. Patients in both groups displayed significant improvements in visual analog scale (VAS) for pain and American Orthopaedic Foot and Ankle Society (AOFAS) Ankle Hindfoot Scale scores six months after surgery, although patients in Group B displayed significant deterioration in these scores over an average follow-up period of 50 months. In addition, more patients in Group A achieved good or excellent AOFAS scores compared to Group B. Surgeons also found that none of the 22 patients in Group A needed subsequent revisions, although 14 of the 22 patients in Group B did. The study's authors did not advise against the use of repeat arthroscopy following failed primary arthroscopic treatment for OLT patients, but said the procedure should be used cautiously.

Practice Management

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Ike Devji, JD, an attorney who has worked with thousands of physicians, says doctors commonly make several legal mistakes when selling their practices. The first of these mistakes is the failure to have independent legal representation. Devji writes that physicians should not seek out legal advice from the practice brokers/attorneys who are involved in the sale of their practice and should instead have their own attorney review the contract. One important area that attorneys may want to focus on is legal structures and contractual protections that can protect a physician from claims filed by doctors who purchase their practice and subsequently fail due to some fault of their own. A second mistake that Devji says he commonly sees is the failure to determine what a practice is actually worth using a formal documented and defensible valuation process. Physicians who are selling their practices should have a team in place to help them understand proper valuation methods and the empirical evidence used to support valuations, Devji says, in part because setting a value for the practice also involves making some specific legal and financial representations that the buyer will depend on and which will create liability for the selling physician. Finally, Devji notes that physicians should be sure not to cancel their malpractice insurance policies after they sell their practices, as they can still be held liable for such claims.


Steven Waldren, the director of the American Academy of Family Physicians' Alliance for eHealth Innovation, says physicians' practices can take three steps to use their electronic health record (EHR) systems more effectively and efficiently. Waldren recommends starting out by closely examining the practice's work flow, paying close attention to what tasks are slowing people down, which employees are having trouble completing their work and which staffers seem to have downtime. "By studying work flow and observing how patients are moving through the system, you can find ways to make the process go more smoothly," Waldren says. Waldren notes that the second step toward using EHRs more effectively and efficiently is to involve all practice staff members in the effort to identify tasks that are slowing them down as well as ways that these inefficiencies can be fixed. Finally, Waldren says physicians should reach out to other physicians to find out how they are successfully using their EHRs.


Concerns about privacy and data security could keep some patients from divulging information when their physician uses an electronic health record (EHR), according to a study published in the Journal of the American Medical Informatics Association. Celeste Campos-Castillo, PhD, one of the study's lead authors, says physicians should address these issues because holding back information can lead to poorer care. For the study, the researchers analyzed results from the 2012 Health Information National Trends Survey and found that 13 percent of patients have withheld information from a physician for privacy and security reasons. A multivariable analysis of the results also revealed a positive correlation between patients withholding information and their physician using an EHR during the patient encounter, according to the study, "The Double-Edged Sword of Electronic Health Records: Implications for Patient Disclosure." Campos-Castillo says "patients should discuss their concerns with clinicians, and clinicians should address privacy issues directly with patients, assuring them about the confidentiality of health information in EHRs."

Health Policy and Reimbursement

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CMS announced that the Open Payments system is once again available for physicians and teaching hospitals to register, review and, as needed, dispute financial payment information received from healthcare manufacturers. The system was taken offline on August 3 to resolve a technical issue. To account for system down time, CMS is extending the time for physicians and teaching hospitals to review their records to September 8, 2014. The public website will be available on September 30, 2014.

A full investigation into a physician complaint found that manufacturers and group purchasing organizations (GPOs) submitted intermingled data, such as the wrong state license number or national provider identifier (NPI), for physicians with the same last and first names. This erroneously linked physician data in the Open Payments system. CMS has implemented system fixes to resolve the issue and revalidated all data in the system to verify that the physician identifiers used by the applicable manufacturer or GPO are accurate and that all payment records are attributed to a single physician. Incorrect payment transactions have been removed from the current review and dispute process, and this data will not be published.


Researchers from RAND Corp. have released a report that criticizes the federal government's 340B program, which provides discounted drugs to safety net hospitals. The report noted that the lack of certainty regarding the program's eligibility requirements as well as poor transparency are creating challenges for healthcare providers. Regulators should address the issues associated with eligibility requirements by considering how to best determine eligibility for the program, the report said. In addition, the report noted that policymakers should provide a clearer direction for the 340B program. Doing so could involve creating a clear, objective description of the program as well as the challenges it faces, the report's lead author said in a statement. This is important because there is a growing diversity of opinions about the purpose of the program and the role it plays in providing support to safety net hospitals, the author said. In addition, RAND called on federal regulators to address the record-keeping difficulties that have been created by a rule issued last month that allows hospitals to continue to use the program to purchase discounted orphan drugs.

Medicine, Drugs and Devices

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A new Phase II study has found that patients who have active rheumatoid arthritis despite having been treated with methotrexate experienced improvements in the signs and symptoms of the disease after being treated with sirukumab. The study was divided into two parts: a proof of concept part (Part A) in which 36 patients were randomized to receive either placebo or sirukumab 100 mg every two weeks (q2w) through week 10, with crossover treatment during weeks 12–22; and a dose-finding part (Part B), in which 151 patients were randomized to sirukumab (100 mg q2w, 100 mg q4w, 50 mg q4w, or 25 mg q4w) through week 24 or placebo through week 10 with crossover to sirukumab 100 mg q2w (weeks 12–24). The study's authors found that the primary endpoint, the proportion of patients with an American College of Rheumatology 50 (ACR50) response at week 12 in Part B, was achieved only with sirukumab 100 mg q2w versus placebo. In addition, larger improvements in the average change from baseline in the 28-joint count disease activity score using C-reactive protein (DAS28-CRP) were observed with sirukumab 100 mg q2w versus placebo in Part A and Part B.


A recent study found that the new IOFIX intra-osseous fixation device improves force distribution across an ankle arthrodesis compared to a single conventional lag screw. The study's authors used both the IOFIX device, which consists of a lag screw inserted into an X-post, and a standard single lag screw on 10 ankles taken from cadavers to measure the amount of force generated by each device. They found that the median average force created by the IOFIX device was 3.95 kg, compared to a median average force of 2.4 kg that was generated by the single conventional lag screw. The study also found that the median average contact area across the arthrodesis was 3.41 cm2 in the IOFIX ankles, compared to a median average of 2.42 cm2 in the single conventional lag screw ankles.