News From ACFAS

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Recent research has found that many surgical residents feel they need better knowledge of the business principles essential to running a healthcare practice. ACFAS invites all members to enhance their business acumen with a pre-conference workshop, “Managing Your Practice,” on March 8, before the start of 2011 Annual Scientific Conference.

This day-long course offers instruction not only in setting up or joining a new practice, but also in 2011 coding & billing changes, electronic medical record implementation to qualify for federal reimbursement, quality initiatives and more. And, you can enjoy a special lunchtime networking opportunity with members of the ACFAS Practice Management Committee.

Don’t delay — get the workshop program now (38 KB PDF), then visit the annual conference website for immediate online registration.
If you haven't already voted, please fax in your ballot for the ACFAS Board of Directors election. They must be received the ACFAS office no later than 5 p.m. CST, Jan. 24, 2011. You can vote for one or two of the three candidates recommended by the Nominating Committee:

• Darryl M. Haycock , DPM, FACFAS
• Laurence G. Rubin, DPM, FACFAS
• John S. Steinberg, DPM, FACFAS

Help decide the future of your College — fax your ballot to 773-693-9304 by Jan. 24!

Foot and Ankle Surgery

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Researchers evaluated the mid-term effectiveness of the Ponseti method for the treatment of congenital idiopathic clubfoot. A total of 49 patients (67 clubfeet) were treated by Ponseti method. The mean follow-up period was 5 years.

The functional Ponseti Scoring System showed good to excellent results in 44 patients. Of the 49 patients who responded to initial Ponseti casting, 14 patients had relapse at varying age, out of which 9 patients were corrected by Ponseti casting method, while 5 patients were resistant to Ponseti method. Poor compliance with the Denis Browne splint was thought to be the main cause of failure in these patients.

The researchers concluded that the Ponseti method is a safe and satisfactory treatment for congenital idiopathic clubfoot with mid- term effectiveness.



Researchers sought to determine whether minimally invasive deltoid ligament reconstruction in conjunction with triple arthrodesis (MIDLR/Triple) allows tibiotalar joint sparing surgical therapy in patients with Stage IV-A acquired adult flatfoot deformity (AAFD). Patients diagnosed with Stage IV-A AAFD were given the option of undergoing ankle joint sparing surgery with the MIDLR/Triple technique. Eight patients underwent the ankle joint sparing procedure. The average follow-up was 36 months. Success was defined as maintenance of 3 degrees or less of valgus tibiotalar angulation and greater than 2 mm of lateral joint space remaining at final follow-up.

At final follow-up, five patients were judged to have a successful outcome. In those, tibiotalar valgus angulation was reduced from 6.4 ± 2.9 degrees to 2.0 ± 2.0 degrees, lateral ankle joint space was maintained at preoperative levels, and SF-12 functional scores were equal to age matched normative scores. The only parameter found to be predictive of successful outcome was the magnitude of preoperative tibiotalar tilt.

The researchers concluded that MIDLR/triple is a new treatment option that requires significant care in patient selection and surgical execution. It is a choice that allows for preservation of ankle motion in patients diagnosed with Stage IV-A AAFD who have less than 10 degrees of valgus tibiotalar tilt on preoperative standing ankle radiographs.




Failure to treat an injury of the syndesmosis after an ankle fracture can lead to a poor functional outcome and posttraumatic arthritis. Researchers reviewed the radiographic and clinical results of salvaging this condition through reduction and arthrodesis of the distal tibiofibular articulation. Ten patients with chronic syndesmotic instability who underwent salvage by a single surgeon were evaluated retrospectively. Five parameters of mortise and syndesmotic alignment were measured on weight-bearing radiographs that were made preoperatively and at the time of the latest follow-up.

After a mean duration of follow-up of 41 months, the medial clear space, talocrural angle, and talar tilt had improved. No ankle demonstrated progression of arthritis on the basis of the radiographic grade. The clinical rating score improved significantly because of improvements in the pain, activity, maximum walking distance, and gait subscales. Two patients had a total of three additional procedures. Both had prominent implants removed, and one subsequently underwent an ankle arthroscopy. All patients reported satisfaction with and a willingness to undergo the procedure again. At the time of the latest follow-up, no patient had undergone an ankle arthrodesis.

The researchers concluded that the results suggest that chronic syndesmotic instability after ankle fracture can be salvaged with reduction and arthrodesis of the distal tibiofibular articulation. Furthermore, the reconstruction of an incongruous and arthritic ankle is an alternative to and may postpone the subsequent need for ankle arthrodesis or arthroplasty.

Practice Management

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Financial decisions for leasing or buying office space for a practice rely on several considerations. Owning property builds equity, but only makes sense if it is not significantly more expensive than leasing space. Leasing may be more prudent when anticipating future growth and building a patient base.

Whether renting or buying, location must be convenient and not too close to other similar practices. Consider parking capacity and how neighbors might affect your practice.

When negotiating the lease, consult area comparables to determine reasonable rental rates. Clarify terms such as hours of operation, ability to handle hazardous materials or operate radiological equipment, and the potential for expansion. Be aware of the building’s occupancy rate, as this can impact variable costs such as utilities and janitorial services. Other issues to negotiate include tenant improvements, default of rent payments, restoring the space to its original condition when vacating, and renewal options.

Engaging the services of a broker, insurance agent, and real estate attorney will help secure a sound lease and navigate unfamiliar terms and conditions contained in most commercial real estate transactions.




If accountable care organizations and healthcare reform practices have a chance of improving quality and lowering cost, primary care providers (PCPs) and specialists must share essential information about their patients in a timely way. But that essential communication happens rarely, report researchers. The researchers analyzed the nationally representative 2008 Center for Studying Health System Change Health Tracking Physician Survey of 4,720 physicians providing at least 20 hours per week of direct patient care. Outcome measures were physician reports of communication regarding referrals and consultations.

Perceptions of communication regarding referrals and consultations differed greatly. For example, 69.3 percent of PCPs reported "always" or "most of the time" sending notification of a patient's history and reason for consultation to specialists, but only 34.8 percent of specialists said they "always" or "most of the time" received such notification. Similarly, 80.6 percent of specialists said they "always" or "most of the time" send consultation results to the referring PCP, but only 62.2 percent of PCPs said they received such information. Physicians who did not receive timely communication regarding referrals and consultations were more likely to report that their ability to provide high-quality care was threatened.

Health Policy and Reimbursement

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CMS has issued a proposal on how they will make value-based purchasing incentives. The document sets forth which metrics will generate payment after Oct. 1, 2012. The proposal incorporates 17 clinical process-of-care measures used in five health categories: acute myocardial infarction, heart failure, pneumonia, healthcare associated infections, and surgical care improvement. It also will use eight measures from the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey that reflects how patients view their care experiences. The proposed rule is available here.



The Medicare Payment Advisory Commission (MedPAC) is proposing that Congress increase payment rates for both hospital inpatient and outpatient prospective payments systems by 1 percent in 2012. The commission also proposes that Congress require HHS to make adjustments to inpatient payment rates in future years to fully recover all over-payments because of documentation and coding improvements.



The Department of Health and Human Services has asked the independent Institute of Medicine (IOM) for advice on what benefits insurers should be made to cover under the healthcare reform law. A 17-member IOM panel—including economists, consumer advocates, a state health commissioner, and a former CEO of insurer WellPoint—kicked off discussions last week on the issue. They’re expected to make recommendations by fall. While the law outlines 10 broad categories of coverage, it leaves the specifics to the government. The Obama administration faces a tough balancing act: the benefits package must be broad enough to be comprehensive but not so broad as to be unaffordable.



The U.S. Supreme Court has upheld an IRS requirement that medical residents pay Social Security taxes. Full-time students who work are generally exempt from Social Security taxes, but law clerks and tradesman apprentices are not. The high court, in a unanimous opinion by Chief Justice John Roberts, upheld a Treasury Department rule that said medical residents are full-time employees, not students.

Medicine, Drugs and Devices

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Animal studies have shown that local application of platelet-rich plasma (PRP) stimulates tendon repair. Researchers set out to determine whether autologous platelet-rich plasma (PRP) stimulates healing of acute Achilles tendon ruptures. Thirty patients were recruited. During surgery, tantalum beads were implanted in the Achilles tendon proximal and distal to the rupture. Before skin suture, randomization was performed, and 16 patients were injected with 10mL PRP (10 times higher platelet concentration than peripheral blood), and 14 were not. With 3-dimensional radiographs, the distance between the beads was measured at seven, 19, and 52 weeks while the patient resisted different dorsal flexion moments over the ankle joint, thereby estimating tendon strain per load. An estimate of elasticity modulus was calculated using callus dimensions from computed tomography. At one year, functional outcome was evaluated, including the heel raise index and Achilles Tendon Total Rupture Score. The primary effect variables were elasticity modulus at 7 weeks and heel raise index at 1 year.

The mechanical variables showed a large degree of variation between patients that could not be explained by measuring error. No significant group differences in elasticity modulus could be shown. There was no significant difference in heel raise index. The Achilles Tendon Total Rupture Score was lower in the PRP group, suggesting a detrimental effect. There was a correlation between the elasticity modulus at seven and 19 weeks and the heel raise index at 52 weeks.

The researchers concluded that the results suggest that PRP is not useful for treatment of Achilles tendon ruptures. The variation in elasticity modulus provides biologically relevant information, although it is unclear how early biomechanics is connected to late clinical results.



An ankle-foot orthosis with an oil damper (AFO-OD) was developed to resist plantarflexion motion, thereby improving hemiplegic gait performance. Researchers set out to determine the effect of the AFO-OD on muscle activity during the gait cycle in individuals affected by stroke. Electromyography (EMG) was used to assess gait at a self-selected speed while wearing an AFO-OD or an AFO with a plantarflexion stop (AFO-PS) worn on the affected side in 11 stroke survivors and on the right side in 11 age-matched healthy adults. EMG signals were obtained from the tibialis anterior (TA), astrocnemius (GAS), and soleus (SOL) muscles. In addition, the ankle joint angle under both braces and the plantarflexion resistance torque (PFRT) under AFO-OD were monitored.

Peak PFRT under AFO-OD was observed during the loading response phase (LRP) in both groups. AFO-OD promoted adequate plantarflexion during LRP in the stroke group, whereas AFO-PS did not. Compared with the AFO-PS, the AFO-OD significantly reduced GAS EMG amplitude during LRP in the stroke group, which was significantly correlated with peak PFRT during LRP.

The researchers concluded that AFO-OD assisted the “heel rocker function” and reduced GAS muscle EMG amplitude during LRP.



Researchers estimated the outcome and complications of surgical treatment of calcaneal fractures using bioabsorbable screws. They retrospectively reviewed 58 patients who underwent surgical treatment using bioabsorbable screws. The minimum follow-up was 15 months.

Fifty-five of the 58 patients healed without additional complications. The mean adjusted AOFAS ankle-hindfoot score was 73.6 ± 22.4, the mean foot function index score was 23.9 ± 7.1, and the mean calcaneal fracture scoring system score was 77.2 ± 8.5. One patient had a superficial wound infection which healed after irrigation and debridement without removal of the implant. Two patients had consistent effusion from the wound for two weeks which healed after drainage and elastic dressing. No evidence of soft tissue irritation or other complications directly attributed to the bioabsorbable screws was identified.

The researchers concluded that bioabsorbable screws provide sufficient stabilization to allow for calcaneal fracture union with the advantage of no implant removal needed.