News From ACFAS

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Over 1,240 foot and ankle surgeons, residents and students and nearly 800 exhibitors gathered deep in the heart of Texas in San Antonio, for ACFAS’ 70th Annual Scientific Conference, March 1–14, 2012. While enjoying good ol’ fashioned Texas hospitality and the energy of the San Antonio River Walk, attendees immersed themselves in the latest podiatric medical and business intelligence, including:

• A riveting opening session by Abraham Verghese, MD, MACP on the Patient-Physician Relationship in the Microaaray Era.
• The most recent research and new discoveries for the practice of foot and ankle surgery presented in panels, debates, workshops, manuscript sessions and scientific poster displays.
• Advances in medical devices, supplies and services from the industries that support podiatric medicine.

Don't miss the most valuable clinical program in the profession. Make your plans now to join us next year for the ACFAS 2013 Annual Scientific Conference, February 11-14, in Las Vegas! If you attended ASC 2012 then you're eligible to download the session handouts. The majority of the handouts are available today for download at the web link below with the full library following suit by the end of the week. Jerome S. Noll, DPM, FACFAS, is the 2012 recipient of the ACFAS Distinguished Service Award. This award, presented annually by the ACFAS Board of Directors, recognizes long-term, behind-the-scenes volunteerism to the profession and the College. Noll was selected this year for his countless ongoing hours of research and preservation of the history of the College.

Dr. Noll was recognized at a ceremony during the Annual Scientific Conference in San Antonio last week.

To hear some excerpts from Noll's research of the College, be sure to read his special 70th anniversary history column in the ACFAS Update newsletter during 2012.
Those of you who were able to attend your ACFAS Regional Division’s membership meeting at the Annual Scientific Conference in San Antonio learned about ACFAS activities in your part of the country. As thanks from the Division leadership, you were also entered in a raffle for a brand-new 32 GB Apple iPad 3.

The drawing has been held, and the iPad winner is:

Nicole Lane Humphries, DPM, Westlake, OH.
Division 13: Ohio Valley

Congratulations to Dr. Humphries, and please stay tuned for e-mails from your Division about ACFAS programming and support in your backyard. To get the latest information online, visit the web link below. There's still time to take part in the ACFAS Research-EBM Committee's survey on DVT Prophylaxis.

If you're a licensed DPM, please take a few minutes to participate in the short 15-multiple-choice-question survey at the web link below.

Special thanks to the 200 members who have already taken part--the goal is to have 500 participants!

The survey closes on April 15, 2012.

Foot and Ankle Surgery

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Research was performed to extend earlier work on assessing the use of oligonucleotide arrays to discriminate colonization from infection attributed to Staphylococcus aureus in diabetic foot ulcers (DFUs). The arrays were used to determine S. aureus resistance and virulence genes, and each isolate was associated with a clonal complex (CC). S. aureus was initially isolated from 75 uninfected and 120 infected ulcers, of which 35 were methicillin resistant. Forty-four strains from uninfected DFUs were affiliated with CC5/CC8 clones compared to six strains from infected DFUs. Follow-up revealed that 57 of uninfected DFUs healed or had a favorable result, and the strain in 49 of them belonged to CC5/CC8. Conversely, 18 had a poor outcome but not one strain belonged to CC5/CC8 clones.


Researchers analyzed changes in multisegmental foot and ankle kinematics in patients who underwent surgical correction of hallux valgus, using a 15-camera Vicon Motion Analysis System to assess 24 feet in 19 patients preoperatively and postoperatively, and the Milwaukee Foot Model to characterize segmental kinematics and temporal-spatial parameters (TSPs). A comparison was made between preoperative and postoperative kinematics and TSPs using paired nonparametric methods, while comparisons with normative data were carried out using unpaired nonparametric techniques. Results were evaluated using the SF-36 assessment tool. Hallux valgus patients exhibited significantly changed temporal-spatial and kinematic parameters preoperatively, while kinematic analysis showed restoration of hallux position to normal postoperatively. Hallux valgus angles and intermetatarsal angles demonstrated substantial improvement, and results indicated a significant increase in physical activity performance. Temporal-spatial parameters and kinematics in the more proximal segments were not significantly altered postoperatively.

Practice Management

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Physicians must become more engaged in partnerships with other stakeholders to surmount turf wars and ego-driven obstructions to coordinate care and enhance patient outcomes, and the HealthLeaders Media Industry Survey 2012 found that 10 percent of doctors blame themselves for the "healthcare industry mess," although 30 percent envision doctors as healthcare's saviors; 13 percent cite a prevalence of physician disrespect and abuse of nurses at their organization. "We order too much, [practice] too much defensive medicine, keep patients in hospitals too long," says Douglas Garland with the MemorialCare Joint Replacement Center. He says doctors must become more practiced in rationing care, while patients must learn as well, noting that "they want their own doc, not a doc in the box; they want the latest and the best."


The Centers for Medicare & Medicaid Services (CMS) has updated its online application system used by physician practices for Medicare enrollment. The system's new capabilities will reduce data entry and increase access to account information, CMS said. Using the CMS' online Provider Enrollment, Chain, and Ownership System (PECOS) is faster than filing applications by mail. The web-based application can be processed in 45 days, compared with 60 days for paper enrollment forms. PECOS now allows users to certify applications using an electronic signature, CMS said. This eliminates a requirement to print and sign a certification statement that must be mailed to a Medicare contractor in order to complete processing. Additionally, physicians can now log in to see if a contractor has issued a revalidation request. CMS has launched a major initiative requiring nearly all physicians and health professionals to re-enroll in the Medicare program by 2015.


DrScore.com, a physician online rating site says a short time in the waiting room and a longer time in the exam room with the doctor are the key components to making patients happy. The site analyzed 36,000 patient satisfaction surveys submitted to the website in 2011 for its Annual Report Card and found that patients do not want to wait more than 15 minutes to see a doctor. Additionally, they expect visits of at least 10 minutes. When those thresholds are not met, satisfaction declines, and physician are less likely to be seen as caring. DrScore is not alone in concluding that experience, rather than clinical quality of care, is the major factor in patient satisfaction. The 2011 Pulse Report by Press Ganey, a health care performance surveyor and consulting firm in South Bend, Ind., also found that "outpatients expect their visit to be quick and efficient."

Health Policy and Reimbursement

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Members of the House Energy and Commerce Health Subcommittee approved a bill to repeal the Independent Payment Advisory Board created in the healthcare reform law. The American Medical Association (AMA) has declared its support for the legislation. Writing to Rep. Joe Pitts (R-Pa.), chairman of the subcommittee, AMA CEO and Executive Vice President James Madara said he supported the Medicare Decisions Accountability Act of 2011. Madara wrote that IPAB's budget targets would be vulnerable to projection errors that would make Congress offset them by seeking cuts elsewhere in the budget. IPAB would have "far too little accountability," Madara added. The Patient Protection and Affordable Care Act called for the creation of the IPAB, a 15-member panel that would have to identify Medicare cuts starting in 2014 if growth per enrollee exceeds targets. The bill now has 226 co-sponsors, including 17 Democrats.

Medicine, Drugs and Devices

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Following an infection discovered in a patient, The Methodist Hospital in Houston examined several surgical instruments that had been properly cleaned, only to find that they were still dirty. The discovery set off alarms that would travel through the larger medical community. Investigators say hospital-acquired infections are notoriously difficult to track to their sources, but Dr. Pritish Tosh, a former investigator at the Centers for Disease Control and Prevention Epidemic Intelligence Service, posits that most infections are a direct result of inadequately cleaned instruments that have human tissue on them.

The U.S. Food and Drug Administration (FDA) held a little-noticed workshop to address concerns regarding dirty devices. During the workshop, Jahan Azizi, a risk management clinical engineer at the University of Michigan Health System, presented the most ominous data and conclusions to the crowd of around 200 government and industry insiders. He blamed poor manufacturer design for the difficulty of cleaning devices, though experts say bad design is but one of a litany of reasons why dirty instruments are being used on patients. They named several other reasons, including the proliferation of highly complex surgical instruments, inadequate device testing by manufacturers, and the struggle faced by poorly-paid hospital employees who clean and sterilize devices between procedures. High-tech creates new cleaning challenges, as devices become smaller, more specialized and complex, made of complicated materials, and often include moving parts. Cleaning has become less of a factory job and more of a laboratory job. Still, despite the Methodist infections and the alarming FDA safety review findings, the agency has ordered no system-wide mandatory check of instruments, and no products have been recalled.



Ankle replacements have proven far more vexing than knee and hip replacements, but some surgeons believe they have the hardware and know-how to effectively replace an arthritic ankle joint. Fixing an ankle replacement is tougher than redoing hip and knee replacements because there is less bone and tissue to work with. According to the American Academy of Orthopaedic Surgeons, only 1,596 ankle replacements were done in the United States in 2009, compared with 621,029 knee replacements and 285,471 hip replacements. Still, Dr. Shane Schutt, a Methodist Hospital orthopaedic surgeon, believes the number of ankle replacements will double in the next 10 years. Schutt estimates that he has placed ankle implants in about 80 patients; and doctors in the U.S. have been using the device Schutt uses, a Scandinavian implant called STAR, for only about 10 years including clinical trials. The data appear promising; a report published last year said 91 percent of 84 artificial ankle joints remained in patients after an average of more than nine years. Despite advances in equipment and technology, some orthopaedic surgeons argue that enough anatomic problems remain to prevent STAR from being a game-changer.


For a study published in Archives of Surgery, researchers from the University of Maryland School of Medicine sent questionnaires to more than 5,000 female surgeons who were in various stages of their careers, asking them about attitudes toward pregnant surgeons. Roughly half of the women responded, and a vast majority reported a significant stigma attached to being pregnant, particularly during training. Over two-thirds of the young women still believed that being pregnant during training could negatively affect or even jeopardize a surgical career. Only 30 percent of surgeons-in-training are female, possible due at least in part to the fact that the most intense period of surgical training correlates to a woman’s most fertile years, her 20s and 30s. There have been official efforts in recent years to improve the work-life balance of surgeons-in-training, and residency programs across the country have been working to limit duty hours to no more than 80 a week. Additionally, the American Board of Surgery has made some of its requirements more flexible, though it probably will not be until those in the youngest generation of surgeons become well established in their careers that significant changes will occur.