News From ACFAS

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Last week all eligible voting members (Fellow, Associate, Life, and Emeritus members) received an email with a unique link to the 2012 ACFAS Board of Directors Election website. The three percent of members without an email address were sent voting instructions by US Mail. The email was sent with the subject line: ACFAS Election – Email Verification.

Your vote is important to help advance our profession and surgical specialty. If you haven’t voted, please take a few minutes today to select members of your Board of Directors who will help lead the College over the next three years. If you have questions accessing the ballot site, please contact our independent election firm at pnentwig@intelliscaninc.com.

Remember to vote no later than January 17, 2012.
The College is recruiting sites for a new multicenter retrospective study on predictive variables associated with successful and unsuccessful outcomes when performing subtalar joint arthroereisis in adults and children. Subjects and sites will be compensated for their time.

Criteria for site selection includes:
1. One-year contract commitment by the investigative site
2. Past participation in multicenter studies
3. Professional reputation for scholarly activity
4. Primary investigator at each site in good standing with ACFAS
5. Volume (minimum of 40) and variety (children and adults) of patients treated for symptomatic non-neuromuscular flatfoot with subtalar arthroereisis during the past 10 years

To learn more about the study and apply, please visit the web link below.
As 2011 comes to a close, ensure the deductibility of your ACFAS dues as a business expense in 2011 by renewing your membership by December 31, 2011.

Payments can be made online, 24/7, through the ACFAS web link below.
You can also remit by calling the College at (800) 421-2237 during normal business hours: 8:30am – 5pm CST.

The College hopes you’ve had a successful year in 2011 and is committed to your continued successes in 2012.
Recently, the Centers for Medicare and Medicaid (CMS) released a new analysis of the Accountable Care Organizations (ACO) regulations.

Regulatory change such as this can influence your practice as a foot and ankle surgeon. Visit the web link below to find useful resources for managing today’s practice, including the 2012 ACFAS Practice Management course schedule.

If you have and questions or concerns, please contact Kristin.Hellquist@acfas.org. The ACFAS Board of Directors and the Division Presidents Council are supporting comments to the Centers for Medicare & Medicaid Services (CMS) regarding the Conditions of Participation (CoPs), including the CMS recommendation that DPMs should head medical staffs.

Visit the web link below to view comments.

If you have any questions or concerns, please contact Kristin.Hellquist@acfas.org.

Foot and Ankle Surgery

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The study measured contact pressure in the ankle joint following osteochondral grafting with different locations and depths using 10 cadaveric specimens. The study tested six conditions—intact, graft flush, graft elevated 1.0 mm, graft elevated 0.5 mm, graft recessed 0.5 mm, and graft recessed 1.0 mm—while a Tekscan sensor measured joint contact pressures as loads of 200 N, 400 N, 600 N, and 800 N were sequentially applied. The peak contact pressure at the graft site for the flush condition did not significantly differ from the intact condition for either medial or lateral lesions, while peak pressure on the opposite facet of the talar dome was substantially higher during the flush condition for the medial but not the lateral grafts. Elevated grafts experienced significantly greater contact pressures, while recessed grafts experienced significantly lower pressures. Lateral lesions exhibited a higher degree of these changes than medial. Reciprocal changes in joint contact pressures were observed on the opposite facet of the talus with elevated grafts on the lateral side and recessed grafts on the medial side.


A study was performed to characterize the potential advantages of peroneal functional electrical stimulation (FES) over an ankle-foot orthosis (AFO) with respect to the ability to negotiate a sudden obstacle in people with stroke-related foot drop. Twenty-four community-dwelling participants with stroke who used a polypropylene AFO on a regular basis were fitted with a transcutaneous FES device, and their obstacle avoidance ability was tested after two and eight weeks. The test involved them having to avoid 30 obstacles that were suddenly dropped on a treadmill in front of the affected leg while walking with either FES or an AFO. Participants who used FES had higher success rates than AFO users, particularly following adjustment for individual leg muscle strength. FES was most likely to benefit participants with relatively low muscle strength in terms of obstacle avoidance ability.


A one-year prospective study was held to determine if basketball players exhibiting a low ankle dorsiflexion range are at a higher risk of developing patellar tendinopathy (PT). The study involved examination of 90 junior elite basketball players for different traits and potential PT risk factors, including ankle dorsiflexion range in the dominant and nondominant leg. The inclusion criteria was fulfilled by 75 players, 12 of whom developed unilateral PT at follow-up. They had a substantially lower average ankle dorsiflexion range at baseline than the healthy participants, with an average difference of -4.7 degrees for the dominant limb and -5.1 degrees for the nondominant limb. It was demonstrated via complementary statistical analysis that players with dorsiflexion range less than 36.5 degrees had a risk of 18.5 percent to 29.4 percent of developing PT within a year, versus 1.8 percent to 2.1 percent for players with dorsiflexion range greater than 36.5 degrees. Limbs that had suffered two or more ankle sprains had a moderately lower average ankle dorsiflexion range versus limbs with no sprains or only one sprain (average difference, -1.5 degrees to -2.5 degrees), but this was only statistically significant for nondominant legs.

Practice Management

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Physician review sites have become quite common, and there is little to prevent a disgruntled patient from launching a nasty attack online. However, doctors are now seeking legal remedies to fight alleged online libel and defamation. For example, an Illinois plastic surgeon sued Google in federal court for failing to remove blog posts the doctor claims are libelous and false, and the Minnesota Court of Appeals recently heard arguments in a case in which a neurologist is suing a former patient's family for alleged defamation, alleging that a family member made derogatory and untrue posts about his father's treatment. Legal experts say that taking legal action against Internet posters is not ideal, and that before suing doctors should consider all legal strategies to help remove negative comments.


Medical ethics experts say physicians should practice common sense when it comes to accepting holiday gifts from patients, and weigh how this could affect their care. "You have to ask yourself, 'What's in the best interest of this patient, and what's in the best interest of your doctor-patient relationship moving forward?'" says Elizabeth Gaufberg, MD, with Cambridge Health Alliance's Center for Professional Development. Healthcare attorney Ericka L. Adler says federal laws ban doctors from accepting gifts from people in a position to refer or generate business for them or anyone with whom they have specific financial relationships; American Medical Association policy, meanwhile, recommends that gifts from patients should not be accepted if they are meant to encourage preferential treatment or if their acceptance creates difficulty for the patient or his or her family.


A recent survey by Medicus Firm showed that older candidates seeking open positions in the medical field seem to be getting overlooked, despite the shortage of doctors. The survey found that 28.6 percent of candidates with 16 plus years of experience received no response from prospective employers, while 8.2 percent with 15 year or less got no response. These younger candidates also got 5.76 more job offers on average in the last two years. International medical graduates, though less frequently tapped than their American counterparts, are receiving a 50 percent response rate from prospective employers. The shortage of doctors sparked the current administration to earmark $1 billion in the speedy training of more healthcare workers.

Health Policy and Reimbursement

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The House of Representatives voted 229-193 on a motion to disagree with a Senate-amended version of a House payroll tax cut bill that would have placed a two-month freeze on payments to doctors. On Saturday, the Senate approved an amended version of a House payroll tax cut bill that the House passed Dec. 13. Both pieces of legislation would avert the scheduled reduction in Medicare physician payments and extend certain healthcare provisions that are set to expire by year's end. But while the House version calls for a two-year fix to the sustainable growth-rate formula and provides a 1 percent update for doctors in 2012 and 2013, the Senate's amended legislation would place a two-month freeze on physician payments until Feb. 29.


The American Medical Association and other physician organizations are speaking out against a proposal from the Department of Health and Human Services that would override laws in 20 states and require laboratories to send test results directly to patients upon request. The proposal does not require physicians to get test results before patients to help them understand the results, and does not distinguish between routine test results and results that can contain news to a potentially life-altering diagnosis. American Academy of Family Physicians President Glen Stream says the proposed regulation could result in patient confusion and undermine patients' relationships with their physicians. "If you do enough tests on any healthy person, some of them are going to be abnormal, so one concern is that people are going to misinterpret insignificant values," says Stream.


The Centers for Medicare and Medicaid Services (CMS) has recommended in a proposed rule that data collection should be postponed in a reform law provision designed to shed light on financial relationships between drug and device makers, GPOs, and healthcare providers. CMS reports that manufacturers and GPOs should not be obligated to start collecting data about such relationships with doctors and teaching hospitals on Jan. 1, 2012, as dictated by the Physician Payments Sunshine Provision in the Patient Protection and Affordable Care Act. The provision mandates that over 1,150 drug, device, biologics, and medical supplies makers that manufacture products covered by Medicare, Medicaid, or the Children's Health Insurance Program must disclose "transfers of value" made to doctors and teaching hospitals, while manufacturers and some 420 GPOs are also required to report doctor ownership or investment stakes.

Medicine, Drugs and Devices

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According to a Joint Commission alert, the healthcare industry has been slow to adopt changes to prevent fatigue-related preventable healthcare-associated mishaps. The commission advises all organizations perform nine tasks to avoid fatigue-related adverse events:

1. Assess your organization for fatigue-related risks, including off-shift hours and consecutive shift work, and review staffing and other policies to address extended work shifts and hours.

2. Assess patient hand-off processes and procedures since these transitions are a time of high-risk for errors related to fatigued staff.

3. Invite staff input into designing work schedules to minimize fatigue.

4. Create a fatigue management plan with scientific strategies for fighting fatigue, such as engaging in conversations with others (not just listening and nodding), doing something that involves physical action such a stretching, consuming caffeine but not at times when one is already alert, and taking short naps of about 45 minutes.

5.Educate staff about sleep hygiene, which includes getting enough sleep and taking naps, engaging in pre-sleep routines such as yoga or reading, and avoiding food, alcohol or stimulants such as caffeine that can impact sleep.

6. Provide opportunities for staff to express concerns about fatigue.

7. Encourage teamwork to support members of the staff who work extended work shifts or hours, such as using a system of independent second checks for critical tasks or complex patients.

8. Consider fatigue as a potentially contributing factor when reviewing all adverse events.

9. Assess the organization's ability to provide sleep breaks to ensure it fully protects sleep to ensure good quality sleep, including providing uninterrupted coverage, response to pagers and phones and coverage of admissions and continuing care, and provide a cool, dark, quiet, comfortable room with eye masks and ear plugs if necessary.


Hospitals and doctors' offices have made substantial investments in computers, smartphones, and other devices so that staff have instant access to important information to enhance patient care, but this is leading to situations in which staff are distracted, placing patients at greater risk. Experts warn that physicians, especially younger ones, are under growing pressure to engage with their devices, and some hospitals seek to address the problem by limiting device use in critical settings.


Discount retailer Costco has entered the health IT business with a nationwide rollout of a cloud-based electronic health record (EHR) designed for small physician practices. The store is offering Allscripts' MyWay EHR through a value-added reseller (VAR), Etransmedia. Costco is pricing its MyWay package at $599 per doctor per month, or $499 for physicians who become "executive members" of Costco. In addition to EHR, the package encompasses an integrated practice management system, a patient portal, training, implementation, maintenance, and claims submission.

Sam's Club, Costco's biggest competitor, launched an EHR initiative in partnership with eClinicalWorks (ECW) and Dell in 2009, just after the passage of the law that authorized the EHR incentive program. However, Sam's Club was unable to sell a sufficient number of packages to physicians and withdrew the offering in March 2011.


A study was held to assess plantar pressure measurements and temporal gait parameters within different ankle-foot orthoses (AFOs), using different numbers of heel wedges. The study involved the evaluation of 15 healthy subjects using three distinct AFOs with four different levels of inserted heel wedges, supporting assessment of 12 conditions in a sequence that was randomly allocated to each subject. An in-shoe F-Scan pressure system was used to measure pressure and temporal gait parameters, while an electrogoniometer was employed to quantify range of movement. AFOs that were restrictive in design, in conjunction with a higher number of inserted heel wedges, lowered forefoot pressures, raised heel pressures, and shrank the amount of time spent in the terminal stance and preswing phase of the gait cycle.


The United States Bone and Joint Initiative (USBJI) is soliciting applications for its grant mentoring and career development program. Experienced researchers will assist early career investigators in securing funding while offering essential survival skills necessary to pursue an academic career. Investigators will maintain a relationship with a mentor until their grant application is funded. The deadline for applications is January 15.