News From ACFAS

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The College’s vast e-Learning curriculum is celebrating its fifth anniversary in 2012. Hundreds of podcasts, streaming videos, and DVD are now online for access 24/7 by College members.

Starting today, access the newest podcast on “Subtle and Missed Injuries” of the Foot and Ankle,” plus a Scientific Session video on “Imaging” (the latter offering 1 CME hour). Click on the link below to see all of the College’s 24/7 e-Learning offerings.
An all-new curriculum will help you “Perfect Your Practice” on February 29, the day prior to the Annual Scientific Conference in San Antonio. Fresh presentations will be feature coding and billing, HIPPA and ICD-10, Financial Strategies for Buying and Selling a Practice, and Beyond Practicing: Retirement Planning. Click below to learn more and register.
Jerome S. “Jerry” Noll, DPM, FACFAS, will receive the ACFAS Distinguished Service Award (DSA) at the 2012 Honors and Awards Ceremony during the March 1-4 Annual Scientific Conference in San Antonio. The DSA is presented annually to an unsung hero who volunteers their time and expertise behind-the-scenes.

Noll will be cited for his many years of service as a regional division president, chair of the Division Presidents Council, member of the Board of Directors, and, in recent years, assuming the role of College historian and archivist. As historian he facilitated and transcribed oral history discussions with ACFAS past presidents and compiled thousands of documents into archival cases now located in the College offices.

To see past DSA recipients, click on the link below.

Foot and Ankle Surgery

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There has been a dramatic drop in the rate of diabetes-related amputations in the U.S., and experts attribute the improvement to better management of risk factors that lead to the loss of feet and legs. The amputation rate declined by 65 percent among adults with diabetes in a little over a decade, the CDC reports. Foot and leg amputations occurred in 4 out of every 1,000 adults with diabetes in 2008, compared to 11 out of every 1,000 in 1996. Non-injury-related amputation rates were still eight times higher among those with diabetes than adults without the disease but the decline shows that efforts to reduce the complications of diabetes are having a major impact, said the researchers.


Researchers reported the results of a direct plantar approach for tendon harvest in the treatment of a dysfunctional Achilles tendon involving transfer of the flexor hallucis longus (FHL). A direct plantar approach to the master knot of Henry with reattachment to its distal stump while protecting the medial plantar nerve was used allowing a double stranded FHL transfer in 25 cases of a severely dysfunctional Achilles tendon in 24 consecutive patients. Patients were evaluated at an average followup of 73 months. No wound healing problems and no lesion of the medial plantar nerve occurred. The subjective result was rated as excellent in 18 (72 percent), good in five (20 percent), and fair in one case (8 percent). The AOFAS hindfoot score averaged 95.4 points and the AOFAS hallux score averaged 97.6 points. No loss of plantarflexion force was observed in the big toe as compared to the contralateral side.


A study was performed to compare the technical challenges, complications, and reduction accuracy in patients undergoing delayed open reduction and internal fixation with those in patients undergoing acute open reduction and internal fixation following ankle fracture. The study involved retrospective review of operative notes, medical records, and radiographs of 23 patients who received surgical treatment for an ankle fracture after a prolonged delay, and comparison with a sample of patients who underwent acute open reduction and internal fixation. The average surgical time was 87 minutes for the delayed group and 76 minutes for the acute treatment group. The researchers did observe a significant difference in the mean lateral malleolus-medial malleolus tip distance between the delayed and acute treatment groups. All patients had postoperative medial clear space measurements of less than 4 mm, and neither group exhibited any talar tilt. No substantial difference between the delayed and acute treatment groups in average documented dorsiflexion or plantarflexion was determined at last follow-up. The delayed treatment group experienced seven complications versus three in the acute treatment group, but no significance was ascribed to the differences in view of the small sample size.

Practice Management

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Patients are seeking help from doctors they have never met via online services like 2nd MD, TelaDoc, and others. These services match patients to doctors and most patients use the service to ask questions about the next steps they can take after receiving a diagnosis. The American Academy of Family Physicians (AAFP) points out that though they have seen many members taking part in this trend, the best help does not come from a doctor that has never met the patient. The AAFP does acknowledge that the fact that patients are seeking help online points to problems in the healthcare system, especially the limited amount of time that a patient gets with the doctor during and office visit.


The rise in physician employment at hospitals and a push toward greater integration between hospitals and physicians due to healthcare reform is blurring the line between medical staff rights and hospital employment obligations. "Physicians need to know what's in their contract and get educated about what rights they do and don't have," says Dennis Maher, the director of legal affairs for the Washington State Medical Association. Jay A. Gregory, chair of the American Medical Association (AMA) Organized Medical Staff Section Governing Council, says the fundamental principle that physicians have the right to treat patients without interference from outside pressures remains, and physicians should not feel pressured to give up that right due to employment.

The AMA handbook on model physician employment agreements and related association policy recommends that employment contracts feature a clause that nothing shall prevent or limit a physician's right or ability to act on behalf of a patient's interest or good care, or to exercise the physician's medical judgment. Gregory says conflict can arise when this right is not clearly defined and when an employer may require something of a physician, like an in-network referral, that may not be in the patient's best interest. Before entering employment at a hospital, physicians must ask themselves, how to get out, what are their rights, and what will they do after hospital employment, according to medical staff lawyer Alice G. Gosfield.


Worry about misunderstandings is one of several reasons doctors are hesitant to share their notes with patients, according to research published December 20 in the Annals of Internal Medicine. The study queried 173 doctors and roughly 38,000 patients at three primary-care practices about disclosing information with patients. After the survey, the practices joined a project called OpenNotes, in which patients received electronic access to their files. More than 90 percent of the patients in the OpenNotes survey said they supported the idea of being able to view doctors' notes.

Health Policy and Reimbursement

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James Madara, executive vice president and CEO of the American Medical Association, has asked House Speaker John Boehner to stop the federally mandated implementation upgrade in October 2013 of the International Classification of Diseases 10th Revision of diagnostic and procedural codes "and to call on stakeholders to assess an appropriate replacement for ICD-9." Madara said the ICD-10 mandate "will create significant burdens on the practice of medicine with no direct benefit to individual patient care, and will compete with other costly transitions associated with the quality and health IT reporting program." He added that the timing of the transition "could not be worse as many physicians are currently spending significant time and resources implementing electronic health records into their practices."


The Centers for Medicare and Medicaid Services (CMS) have made guidance on electronic health record (EHR) incentive appeals available for download from the CMS Web site for hospitals and healthcare professionals that have been labeled ineligible to participate in the program or refused meaningful user status. The site reports that the appeals deadline for hospitals has been extended from Dec. 31, 2011, to Jan. 30, 2012. CMS has entered into a contract with Provider Resources of Erie, Pa., to work with CMS' Office of Clinical Standards and Quality (OCSQ) "to provide customer service support and technical assistance" to providers pursuing an appeal of a decision involving the EHR incentive program. Appeals decisions will be posted at OCSQ Appeals starting in February.


Physician organizations are asking Congress to use money that had been projected to be spent on the wars in Iraq and Afghanistan to pay for a permanent alternative to the sustainable growth-rate (SGR) formula used to calculate Medicare payments to doctors. Using excess baseline projections for Overseas Contingency Operations amounts to "cleaning the books" and will allow the elimination of a "flawed budget gimmick," physician organizations stated in a letter signed by 110 state medical associations and specialty societies. Unless Congress takes action, doctors will have their Medicare payment cut by 27.4 percent on March 1 under the current SGR formula. According to the letter, if the SGR had been repealed in 2005, the resulting cost would have been $48 billion, but now that cost is $290 billion "and growing rapidly."

Medicine, Drugs and Devices

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A study by the not-for-profit Partners HealthCare shows that physicians who own their practices may require more help in implementing electronic health records (EHRs) than those who do not own a practice. In a survey of more than 150 physicians, more than half said implementation was "somewhat difficult," and 35 percent called EHR implementation "very difficult." About a quarter of responding physicians without an ownership stake in their practices said they considered implementation very difficult, but among physicians with partial of full ownership that number jumped to 38 percent. The study's authors say physician owners may think the implementation process is more difficult because they need to consider the financial risks involved with EHR implementation. The study was published online in the Journal of the American Medical Informatics Association.


Under the terms of bills proposed in Florida, physicians and certain medical care centers would be required to post signs of about 3-feet-by-5-feet showing the prices that would be charged to people paying out of pocket. The bills also mandate that hospital-owned urgent care centers disclose if they charge emergency room prices, while extra fees for patients who cannot control whether they receive treatment from someone out of their insurance network would be waived. The patient only would pay the co-payment and the deducible charged by the insurer for in-network treatment. Lobbyists of physicians, hospitals, and other businesses oppose the legislation, claiming that the rules are intrusive and punitive.


At least two states, New York and Tennessee, have pending legislation mandating that physicians must access computerized drug monitoring databases whenever they write a prescription for a controlled substance, to address database underuse. "It tells me that the seriousness of the prescription drug problem in some states is reaching a level of people feeling like, 'We have to do something, and this is the approach we are taking,'" says National Alliance for Model State Drug Laws executive director Sherry Green. New York Attorney General Eric Schneiderman drafted a proposed bill requiring the Department of Health to set up and maintain a database capable of real-time information capture, as well as check the database every time a doctor writes a prescription for a schedule II, III, IV, or IV controlled substance. Some states are attempting to enhance educational initiatives to boost physicians' awareness of the databases and produce best practices for using them, while other states are concentrating on technological improvements so physicians can obtain information faster and more efficiently.