News From ACFAS

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The election for two new ACFAS board directors will start this Friday, December 16, when eligible voters receive an e-mail from acfas.ballot@intelliscaninc.net. This e-mail will contain a personalized link to the election website. Candidate profiles and position statements will appear first, followed by the ballot. Profiles are also visible now at the web link below. Members without email will receive instructions via US Mail on how to vote via the Internet. As mentioned in an earlier edition, ACFAS was successful with the help of the Joint Commission in persuading the Centers for Medicare and Medicaid Services (CMS) to recommend that DPMs be allowed to serve as president/chief of staff for the medical staff.

ACFAS is drafting formal comments supporting this important change for its foot and ankle surgeon members. Unfortunately, the American Medical Association (AMA) is fighting many of these changes, including what they view to be an expansion of the list of non-physician practitioners who may hold medical staff leadership positions.

Through a letter campaign, AMA and their constituents are actively lobbying medical staff leadership across the country to personally and through their medical society, lobby CMS to not make the change. We urge ACFAS members and their supporters to contact CMS directly See draft rule and comment procedures to support the changes to the Conditions of Participation (CoPs) for all hospitals at the web link below. All comments are due no later than December 23. The ACFAS Board of Directors adopted a revised "Model State Scope of Practice Act" for foot and ankle surgeons at its November meeting. As recommended by the Professional Relations Committee, the updates to the Model Legislation include an emphasis on DPMs being allowed to diagnose and treat patients related to, “ailments of the human foot, ankle and other related structures of the lower extremities.” ACFAS is ready to assist its members seeking legislative and regulatory advancements to the practice of foot and ankle surgery.

To view the model legislation and related resources, visit the web link below. If you have concerns or related information, please contact Kristin.Hellquist@acfas.org.

Foot and Ankle Surgery

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A study was performed to evaluate the impact of curettage primarily on cicatrization or healing time and secondarily on postoperative bleeding following segmental phenolization for the treatment of onychocryptosis. Fifty-one patients, or 80 feet, with stage I or IIa onychocryptosis were included in the randomized, double-blind, parallel-group, controlled clinical study. Some 137 phenolizations were executed on affected folds of ingrowing hallux nails, and each hallux was randomly assigned to either a group that underwent phenolization with curettage, or a control group that only underwent phenolization. Curettage lowered healing time to 7.49 plus or minus 1.76 days, compared to 12.38 plus or minus 3.01 days in the control group. It also increased postoperative bleeding, resulted in lower rates of infection, and increased postoperative pain.


A study was conducted to evaluate the clinical outcomes of reconstructive surgery using a bone-patellar tendon (BPT) autograft for athletes exhibiting intractable insertional Achilles tendinopathy. The study included 10 athletes to whom surgery was administered. Indications included persistent symptoms despite conservative therapy for six months, and diffuse high-intensity changes of a full cross-section of the tendon at its insertion point on T2-weighted magnetic resonance imaging (MRI), with clinical follow-up of more than two years post-surgery. Clinical assessment was carried out prior to surgery and at the most recent follow-up, and radiological evaluation at 12 months following surgery. The average Achilles tendon rupture score at the most recent follow-up was 92.5 points, and the average visual analogue scale score experienced significant improvement from 90 points preoperatively to 5 points at the most recent follow-up. T2-weighted MRI showed that the anterior-posterior width of the grafted BPT was about twice that of the intact nonsurgical contralateral tendon insertion in all patients at one year after surgery. The average time from surgery to ability to return to full sports activity was 13.5 months.


Researchers compared the adverse effects between unplanned and planned surgical excisions of malignant soft tissue tumors of the foot by retrospectively reviewing the clinical records, radiographs, pathology reports and pathological specimens of 14 consecutive patients with soft tissue sarcoma of the foot among 592 with sarcomas between 1973 and 2009. They then compared the incidence and clinical outcomes after unplanned (UT; n = 5) and planned (PT; n = 9) surgical excisions of the foot sarcomas. The most frequent diagnosis was synovial sarcoma (n = 4; 28.6 percent). The overall 5-year survival rates of the PT and UT groups were 65.6 percent and 60.0 percent, respectively, and the event-free 5-year survival rates were 63.5 percent and 40.0 percent, respectively. Event-free and overall survival rates did not significantly differ between the two groups. However, tumors were significantly larger in the PT group than in the UT group (p < 0.05).

Practice Management

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The Association of Medical Directors of Information Systems (AMDIS), the Chan Soon-Shiong Family Foundation, the Optum Institute for Sustainable Health, and Siemens Healthcare have joined together to create a new social-media project that will allow physicians to share information about patient safety and efficiency. "Our goal is to help other doctors navigate how to use health IT to make care better, safer and more effective," said AMDIS member Peter Basch. Basch, who is also a founding member and board chairman of the new joint operation, added that it is important now to utilize health information technology with meaningful-use incentives being offered by the state and federal government.


A study published in the Annals of Internal Medicine shows that physicians taking a one-hour, computer-based tutorial on spotting instances where patients require emotional consolation were 30 percent more likely to make statements of empathy during patient visits than those who did not take the tutorial. The physicians also were twice as likely to respond to patients' emotional expressions with empathic expressions. "Good communication ... improves patient adherence and real hard outcomes of various sorts, and it certainly affects issues such as patient satisfaction and quality of life," says lead study author James A. Tulsky, who also noted that an hour-long computer program costs less money and takes less time than other forms of communication training.


The Academic Group's Peter Leone Sr. offers five reasons why a doctor seeking medical malpractice insurance coverage should hire a reputable broker or agent. An agent can examine the potential for carrier insolvency or other adverse financial ramifications that result in insolvency, as well as tell physicians whether new market entrants present better opportunities than their current carrier. In addition, a strong agent experienced in medical malpractice claims can review pricing for appropriate tiering, act as an advocate during the pendency of a claim, and function as a valuable counterweight to poor carrier behavior and other carrier intangibles.

Health Policy and Reimbursement

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The U.S. House of Representatives has approved a payroll tax extension bill that includes a two-year fix to the physician payment formula and averts a looming 27.4 percent payment cut to the nation's doctors. The measure would provide a 1 percent payment increase to physicians in 2012 and 2013. A temporary, $38.9 billion fix to the sustainable growth-rate, or SGR, formula, is intended to give lawmakers some more time to find a more permanent solution to how physicians are paid through the Medicare program. Hospital groups expressed strong opposition to the bill in a letter to federal lawmakers. In it, the provider groups said they approve a solution to the physician payment system, but not through the roughly $17 billion in reduced payments to hospitals that the bill includes. A Statement of Administration Policy from the White House indicated that President Barack Obama will veto the bill if he is presented with it. Meanwhile, Senate Democrats have indicated they intend to prevent the steep cut to physicians that is scheduled to take effect on January 1, but that they still are working on plans to do so.


The Centers for Medicare & Medicaid Services (CMS) has created a new federal option to help physicians who have been victimized by identity theft restore his or her financial integrity and clear fraudulent debts. The provider victim validation/remediation initiative for physicians program allows physicians to seek resolution from Medicare program safeguard and zone program integrity contractors. These contractors can investigate instances of identity theft, and would investigate a physician's complaint and generate a report to CMS for "a final decision whether to relieve providers of liability based upon the evidence." Physicians who believe they are victims of identity theft but have not yet suffered any financial losses or liability should call their Medicare administrative contractors or the HHS Office of Inspector General.


Medicare will permit the rating of doctors by employers, insurance firms, and consumer groups through the use of its extensive claims database. The Medicare files will make physicians individually identifiable, but the confidentiality of personal patient data will be maintained.

Medicine, Drugs and Devices

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Researchers compared the costs of operative treatment of a lateral malleolar fracture using a TriMed Sidewinder plate with a neutralization plate and lag screw approach for the treatment of Weber B ankle fractures. Costs of implants, operating room costs and time to healing were compared between the two cohorts. The average implant cost for the TriMed plate ($1141) was significantly higher than that of the plate and lag screw construct ($208; P<0.0001). However, the average operating room costs were significantly lower for the TriMed group ($4410) compared with the control group ($6037; P<0.01). The average time to healing was also significantly less in the TriMed group (75 days) than in the control group (97 days; P<0.04). The decreased dissection required to apply the TriMed plate could explain the quicker healing observed, the researchers concluded.


Hospitals in the United States looking to cut costs as the economy faltered started with basic supplies like lightbulbs and bandages but have moved on to more complicated devices like artificial hips and knees. Implantable devices account for a significant portion of hospital budgets, and administrators are developing new ways to reduce those costs as they prepare for cuts to government reimbursements. Preparing for these challenges means carefully working through each device category. Such efforts often include creating databases of shared information on pricing between hospitals. "We are pressing very hard on device makers because it is a big piece of the supply puzzle," says Michael Rosenblatt, vice president of supply chain management for SSM Health Care. Heart and orthopaedic device manufacturers have already had to lower their prices as patients forgo expensive treatments. Prices are falling on devices like pacemakers and defibrillators, as well as orthopaedic implants.


Apple is promoting the use of iPads in hospitals. Afshad Mistri is Apple's medical market manager is working to put iPads into the hands of doctors, and the effort seems to be working. A growing number of hospitals are either using or considering iPads, but Apple must walk a fine line in the medical industry. Currently, the Food and Drug Administration seems intent on regulating the software that runs of the iPad, and if the FDA decides that Apple is marketing the iPad for regulated medical uses it could issue strict regulations for the device.

Doctors at Johns Hopkins can save up to an hour and a half per day by using the iPad. Many doctors report that bringing an iPad to the bedside allows them to administer a far more intimate and interactive level of care than they previously believed possible. Hospitals can be rather slow adopters of new technologies, but the iPad has enabled doctors to read papers and look up information no matter where they are.