News From ACFAS

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After careful review and consideration of applicants to serve on the ACFAS Board of Directors, the Nominating Committee will recommend these five Fellows for three positions in the upcoming electronic election:

• Laurence Rubin, DPM, FACFAS (Incumbent)
• John S. Steinberg, DPM, FACFAS (Incumbent)
• Byron Hutchinson, DPM, FACFAS
• John T. Marcoux, DPM, FACFAS
• Randal Wraalstad, DPM, FACFAS

Two, three-year terms and one, two-year term will be filled by election. Candidate profiles and position statements will be posted on acfas.org/nominations in late November. The ballot order is prescribed in the bylaws. Eligible voters may cast one, two, or three votes on their ballot. Regular member classes eligible to vote are: Fellows, Associates, Emeritus (formerly Senior) and Life Members. Individuals who intend to nominate by petition must notify ACFAS by November 7 and petitions are due no later than November 30 (see web link below).

ACFAS will use electronic voting again this year from December 15 to January 14. All eligible voters will receive an e-mail with special ID information and a link to the election website no later than December 14. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot. Eligible voters without an e-mail address will receive paper instructions on how to log in to the election website and vote. There will be no paper ballots.

The 2013 Nominating Committee was Michelle L. Butterworth, DPM, Chair; Michael T. Ambroziak, DPM; Jordan P. Grossman, DPM; Jerome S. Noll, DPM; Gregory P. Still, DPM; James L. Thomas, DPM; and Eric G. Walter, DPM. Did you know that the Gaylord Palms Resort and Convention Center, the site for the ACFAS 2014 Annual Scientific Conference in Orlando, recently joined the Marriott Rewards network? When you book your hotel room you’ll automatically earn points toward your Marriott Rewards account. ACFAS 2014 is February 27 to March 2. Book your room now and see the online program at acfas.org/orlando. Printed programs will be mailed soon. The ACFAS Fellowship Committee recently determined that the following fellowships meet the minimal requirements to receive Recognized Status with the College:

• The Limb Salvage and Reconstructive Surgery Fellowship in Dunmore, PA; led by Program Director Guido A. LaPorta, DPM, FACFAS
• The Professional Education and Research Institute Surgical Fellowship in Roanoke, VA; led by Program Director Charles M. Zelen, DPM, FACFAS

The following fellowship has been granted Conditional Status with ACFAS since the program has not yet had a fellow matriculate through in its current location:

• Podiatric Medicine and Surgery Research Fellowship – Providence VA Medical Center in Providence, RI; led by Program Director Vickie Driver, DPM, FACFAS

The following fellowships have been granted Conditional Status with ACFAS since the programs are new and have not yet had a fellow matriculate through:

• Fellowship in Pediatric Podiatry and Reconstructive Foot Surgery in Temple, TX; led by Program Director Richard N. Goad, DPM, FACFAS
• The Southeast Permanente Foot & Ankle Trauma & Reconstructive Fellowship in Atlanta, GA; led by Program Director Daniel J. Tucker, DPM, FACFAS

Dr. Tucker’s program is seeking interested applicants for the 2014-2015 fellowship year; if you are interested, please submit an application. Initial interviews will be held at the ACFAS 2014 Annual Scientific Conference in Orlando, with final interviews to follow in Atlanta. Selected interviewees will be contacted prior to the Annual Scientific Conference.

All Conditional Status programs will be considered for "Recognized Status" with ACFAS after the first fellow completes the program. ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit our Fellowship Initiative page to review a complete listing of programs and minimal requirements. If you’ve changed any information about your practice, don’t forget to update your profile so the College and potential new patients can reach you. Remember to include updates to your practice’s website; any email addresses you use (work or personal), your fax number; and your work, home or cell number. Do you want to change your “preferred address” for receiving the Journal of Foot & Ankle Surgery and other valuable ACFAS mailings? Make sure you log in and update your member profile at acfas.org/profile so we can stay in touch with you and ensure proper delivery.

Your contact information can also be listed in the College’s online membership directory so your colleagues can find you by clicking “Yes” to the Members-Only Directory in your profile. And, don’t forget to include yourself in the “Find an ACFAS Physician” search tool on FootHealthFacts.org so consumers can find you by clicking “Yes” for “Consumer Physician Search.”

Change can be a wonderful thing, but remember to let us know about any updates so you can keep yourself available to peers, potential patients and the College! Update your profile today.

Foot and Ankle Surgery

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Researchers in Italy have performed a systematic review of 12 studies in order to examine clinical and functional outcomes and complications following open and minimally-invasive surgery for Achilles tendon ruptures. Of the 12 studies that were examined during the review, six were retrospective, five were randomized control trials and one was a prospective investigation. A total of 781 Achilles tendon rupture patients were involved in the 12 studies. Open repair was performed on 375 patients and percutaneous surgery was performed on the remaining 406. Researchers noted that different procedures were performed for open and minimally-invasive repair. The review found that the range of motion was significantly greater following percutaneous repair than it was after open surgery. However, more complications were seen in patients who underwent open surgery than in those who were treated with minimally-invasive surgery. Researchers noted that minimally-invasive surgery and open surgery of the Achilles tendon are grossly equivalent. Finally, researchers said that novel percutaneous repairs have been proposed to reduce the risk of injury to the sural nerve.


The use of lateral column lengthening along with an assortment of other surgical procedures brings about favorable medium-term functional outcomes in children with symptomatic pes planovalgus, a recent study has found. During the study, surgery was performed on 25 symptomatic planovalgus feet in 15 children, a group that mostly included patients who had idiopathic pes planovalgus but also included some with overcorrected club foot and skewfoot deformity. Surgeons performed lateral column lengthening on these children using a tricortical interpositional os calcis bone graft, a procedure which was followed by so-called "a la carte" elements of the surgery. These included both bony and soft tissue elements: heel shift, medial cuneiform osteotomy with iliac crest tricortical bone grafting, peroneus brevis/peroneus longus transfer, plantar fascia release, and tibialis posterior advancement. After an average follow-up period of four and a half years, surgeons observed that the reconstituted medial arch was maintained in all patients. Visual Analogue Scale Foot and Ankle (VAS FA) and American Orthopaedic Foot and Ankle Society (AOFAS) scores were 82±17 (50–99), 87±14 (61–100) and 80±10 (62–100), respectively. A second corrective procedure was required for five feet.


A recent study examined the lateral stabilizing role of the deltoid ligament complex against supination/inversion in case of existing lateral instability. In doing so, researchers hoped to provide orthopaedic and/or trauma surgeons with quantitative data that may be referred to the substantial stabilizing effect of the tibiocalcaneal ligament (TCL) against supination/inversion in the ankle joint in case of repetitive sprain trauma at a present lateral ligament lesion. During the study, a torsion simulation was performed on 12 fresh human lower leg cadaver specimens in a loading frame and a specially designed mounting platform. The preset torsion between the tibia and calcaneus was primarily set at 30 degrees of internal rotation on the specimen in plantar flexion and hind foot inversion. The measured variable was the resisting torque recorded around mechanical tibial axis. The first series of measurements were performed on healthy specimens and the following after transecting structures in the following order: anterior talofibular ligament (ATFL) in combination with calcaneofibular ligament (CFL), the anterior tibiotalar ligament and posterior tibiotalar ligament, and finally the TCL. The combined lateral ATFL and CFL instability displayed a decrease in the resisting torque, which helps ensure stability in ankle sprain trauma. Researchers also observed a significant decrease in torque only in a transection of TCL (superficial layer of deltoid ligament complex) with existing lateral dual-ligament instability. The study concluded that the diagnosis and treatment of lateral ligament instability needs to take into consideration the deltoid ligament complex, especially TCL in clinical routine.

Practice Management

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Medical practices looking to boost their productivity and increase their efficiency may want to turn to scribes for help. Medical scribes are unlicensed, trained medical information managers who are primarily responsible for charting physician-patient encounters during medical exams. In addition, scribes can check the progress of and review X-rays and other patient evaluation data for comparison. The scribe can then transcribe the results of these evaluations onto the patient's chart so that the patient's workup is complete, which in turn helps the doctor make good decisions about treatments. By taking on these and other responsibilities, scribes can help the doctors they work for spend more time with their patients while simultaneously ensuring that the documentation they work on is accurate. Doctors who want to hire scribes for their practices should look for several characteristics in prospective candidates, including knowledge of medical terminology, the ability to recognize the physical exam process, and the ability to record the details of exams. Once a scribe is hired, practices should examine a number of metrics to determine if scribes are helping improve efficiency and productivity, including the number of patients seen per hour or per shift and average charge per billable visit.


Doctors who are concerned about disgruntled patients taking to the Web to voice their opinions will often not be able to retaliate by filing defamation lawsuits against the patients in question, writes health law attorney Lee J. Johnson. That is because posts on physician review sites, social media, and blogs often consist of complaints that are opinions, and thus cannot be proven true or false, Johnson says. As a result, Johnson adds, complaints about doctors not listening to patients or being sloppy in the care they provide are not grounds for defamation suits. However, a doctor could sue a patient for making a statement on the Web that could be proven false, Johnson writes, assuming also that the physician can prove that the statement has caused some type of damage. Johnson notes that physicians should respond to bad patient reviews that do not rise to the level of defamation by getting in touch with the patient in a non-confrontational manner and proposing a solution to his or her concerns. The practice's staff members could also be instructed to make a follow-up call to ask if the patient is satisfied with the proposed solution, Johnson says. Finally, Johnson notes that physicians can ask their satisfied patients to post their opinions online to counter the charges made by disgruntled patients.

Health Policy and Reimbursement

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Health and Human Services Secretary Kathleen Sebelius has said that she will be unable to testify about the problems with the health insurance exchange Web site before the House Energy and Commerce Committee on Thursday, but that she will appear before the panel on Oct. 30. A spokeswoman for the Department of Health and Human Services also said that other HHS officials will testify before Congress about the problems with Healthcare.gov as soon as next week. Opponents of the Affordable Care Act, including Energy and Commerce Committee Chairman Fred Upton (R-Mich.), have highlighted the problems that have appeared on the Web site after it was launched on Oct. 1, including problems with the account creation and login processes. Both Sebelius and President Obama have promised to correct the issues.


Despite calls from some congressional Republicans for the Affordable Care Act (ACA) to be defunded, the spending agreement that was signed by President Obama mostly leaves the healthcare reform law intact. The only provision in the agreement that deals with ACA requires the Department of Health and Human Services (HHS) to implement procedures for verifying the income of people who apply for federal subsidies to help them purchase health insurance coverage on the ACA's health insurance exchanges. This comes after the Centers for Medicare & Medicaid Services had said in July that the exchanges would not need to verify the income of all people applying for subsidies. HHS Secretary Kathleen Sebelius will be required to submit a report to Congress on those procedures by Jan. 1. The agreement also calls for the HHS Office of the Inspector General to submit a report to Congress by July 1 on the effectiveness of the measures HHS is using to prevent fraud and identify inaccurate information in applications for the subsidies.


Peter B. Anderson, MD writes that the payment reforms included in the Affordable Care Act (ACA) are necessary, and that concerns about the potential negative impact these reforms will have on physicians are unfounded. Anderson says that the traditional fee-for-service payment system is unsustainable because it does not incentivize healthcare providers to provide quality care in a more cost-effective manner. But using quality metrics that bundle payments, as outlined in the ACA, could allow improvements in healthcare quality, increase coordinated care, decrease billing complexity, and help bring about better outcomes for patients, Anderson writes. However, Anderson notes that some have criticized the move to bundled payments. These concerns are based on the assumption that reforms to general and bundled payments will encourage providers to cut back on appropriate care in addition to unnecessary or defensive medicine-based care, he says. But there are several safeguards in place that will prevent this from happening, including the ACA's restrictions on Medicare service reductions, as well as provisions that force beneficiaries to pay more of the costs of their healthcare. Anderson also notes that doctors will continue to provide appropriate care because they have taken the Hippocratic oath and because their consciences will oblige them to do so.


A survey of hundreds of physicians in six states has found that problems with electronic health records (EHRs) and the burden of regulations imposed by the federal government and others are having a negative impact on the job satisfaction of doctors. The survey, which was commissioned by the American Medical Association (AMA), found that the majority of doctors want to continue to use EHRs instead of paper records even though they expressed frustration with expensive and excessively-complicated systems that have not improved the efficiency of their practices. Mark Friedberg, MD, the study's lead author, said that physicians' frustrations with EHRs cannot be chalked up to a simple lack of familiarity with the systems, since the study found that there was no relationship between increased doctor satisfaction and more experience with EHRs. AMA President Ardis Dee Hoven, MD, agreed, saying that physicians' frustrations with EHRs have been caused more by usability issues, standards that are not practice- or speciality-specific, and the failure of some EHRs to work properly. The study also found that the burden of rules and regulations implemented by the government, payers, and other players in the healthcare system are having a negative impact on physician satisfaction. Friedberg said that the problem of physician dissatisfaction was "vexing" and that it could herald future quality problems in the healthcare system.

Medicine, Drugs and Devices

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Researchers who recently performed an analysis of seven prospective randomized controlled trials have concluded that extracorporeal shockwave therapy (ESWT) is a safe and effective way to treat plantar fasciitis patients who are still symptomatic even after undergoing other forms of treatment. The analysis showed that patients who underwent ESWT had better composite visual analogue scale (VAS) scores and experienced larger reductions in their absolute VAS scores than did patients who were given a placebo. Patients treated with ESWT displayed improvements in pain scores 12 weeks after treatment. These improved pain scores were maintained for as long as 12 months afterward. In addition, greater success of improving heel pain by 60 percent was seen in patients when taking first steps and during daily activities after undergoing ESWT. These findings led researchers to conclude that plantar fasciitis patients who still have substantial heel pain after undergoing at least three months of nonoperative treatment should be treated with ESWT.


The Agency for Healthcare Research and Quality has released a toolkit that doctors' practices can use to improve the management of their laboratory test processes. The goal of the toolkit, which was developed by a team of researchers led by Milton Eder, PhD of the Access Community Health Network in Chicago, is to help practices find ways to improve processes for tracking, reporting and following-up with patients after they undergo lab tests. The toolkit includes a step-by-step guide for evaluating the lab test process, identifying aspects of the process that can be improved and minimizing the impact from any deficiencies in the process that may exist. Practices can also use the toolkit to assess office readiness, plan activities, engage patients, audit their efforts and incorporate electronic health records into their laboratory test processes. Finally, the toolkit offers practices a template that they can use to ensure that lab results are properly communicated to patients who speak Spanish, as well as those who speak English. The Agency for Healthcare Research and Quality hopes the toolkit will help improve patient safety.


A recent study is the first to show that the use of custom foot orthoses (FO) brings about changes in muscle activation profiles and foot motion characteristics in patients with rheumatoid arthritis (RA), ultrasound (US)-confirmed tibialis posterior (TP) tenosynovitis and associated pes plano valgus. During the study, RA and US-confirmed TP tenosynovitis patients underwent gait analysis, including three-dimensional (3D) kinematics, kinetics, intramuscular electromyography (EMG) of TP and surface EMG of tibialis anterior, peroneus longus, soleus and medial gastrocnemius. Findings were then compared between barefoot and shod with customized FO conditions. A comparison between barefoot with shod and FO showed an altered timing of the soleus and medial gastrocnemius and increased magnitude of tibialis anterior. Differences were also seen in the shod with FOs in terms of peak rearfoot eversion, peak rearfoot plantarflexion and peak forefoot abduction compared to barefoot conditions. However, researchers did not observe any differences in kinetic variables. Researchers also noted that additional studies need to be done to determine whether the complex adaptations that were seen in this cohort of patients resulted in improvements in symptoms.