News From ACFAS

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ACFAS’s monthly Scientific Literature Reviews (SLRs) go beyond just podiatry journals for the latest clinical studies, case reports, and much more. Click on the link to see the March edition including these and other abstracts

• Systematic Review of Patient-Reported Outcome Measures Used to Assess Achilles Tendon Rupture Management: What’s Being Used and Should We Be Using It?
• Relapse After Tibialis Anterior Tendon Transfer in Idiopathic Clubfoot Treated by the Ponseti Method
• Functional Treatment After Surgical Repair for Acute Lateral Ligament Disruption of the Ankle in Athletes

ACFAS’s new Credentialing and Privileging Advisors Team (CPAT) is ready to help! Eleven DPMs who’ve all served on hospital privileging committees have gone through special training to advise fellow members on how to navigate the rocky waters of hospital credentialing and privileging. Three cases have already been assigned this week. It’s simple, just send an e-mail to credentialing@acfas.org with a brief description of your dilemma and you’ll hear from a peer advisor within a day or two. ACFAS is looking for member volunteers to be part of a new College-led research initiative, with Adam E. Fleischer, DPM, MPH, FACFAS, as the study's principal investigator. We are recruiting investigative sites for a retrospective study looking at 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. If you are interested in participating in this important study, please complete and return this PDF Application (64 KB PDF) or submit via online application form to Dr. Fleischer.

Legal Briefs

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A plastic surgery center removed a podiatrist from ownership and refused to return his share, saying he violated ownership rules by wooing a competing surgical center. The podiatrist sued the center to recover his investment. But when he questioned the veracity of the center's medical director in an e-mail to current owners, the medical director sued him for defamation.

Patrick J. Caputo, DPM, was a minority owner of the Riverside Plastic Surgery and Sinus Center in Red Bank, N.J. He was allegedly interested in joining a new surgery center being planned in the area and talked to its owners, giving them names of other doctors they might want to recruit. Frank Scaccia, MD, a facial plastic surgeon and medical director of Riverside, told Caputo he had violated the terms of the operating agreement, stating that shareholders should not assist a competing surgery center. Because Caputo was being terminated for cause, Scaccia would not return Caputo's $12,000 original investment plus his share of the center's profits.

While Caputo did not dispute his removal from Riverside, he did dispute the loss of his investment and sued Riverside to get it back. Caputo made allegations against Scaccia in an e-mail to 2 other partners at Riverside that Scaccia said were untrue, leading to defamation charges against Caputo.

Interpreting the terms of the operating agreement, the trial court determined that Caputo should get his original investment back, plus his share of ASC profits, but threw out the defamation charge. Scaccia appealed the decision. The appeals court disagreed with the trial court on its handling of the defamation charge and remanded it back to the court for a retrial. The appeals court upheld the award of damages, but the money is being held in escrow until the defamation lawsuit is decided.

Fredric L. Shenkman, the attorney for Scaccia, says the decision offers several lessons. "Surgery centers have to be careful with the language in their operating agreement," making sure it won't be open to interpretation. He added, "this is an ongoing challenge," because there are so many ways to interpret language.

Foot and Ankle Surgery

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Researchers evaluated the outcomes of arthroscopic debridement and microfracture for isolated osteochondral lesions of the talus. Twenty-four patients (25 ankles) with isolated osteochondral lesions of the talus were treated by arthroscopic debridement and microfracture. The patients were followed for an average of 32 months. AOFAS Ankle-Hindfoot results were excellent in 13 feet (52 percent), good in nine (36 percent), and fair in three (12 percent). Mean AOFAS scores improved from 61 points (range, 49–78) preoperatively to 89 points (range, 74–99) at final follow-up. Visual analogue scale (VAS) scores improved from 8 points (range, 4–8) to 2 points (range, 1–5), and Short Form-36 scores showed improvements in physical function, pain, social function, and general health. The researchers also found that longer symptom duration had a negative effect on the outcome, as determined by AOFAS scores and VAS scores.


Researchers evaluate the feasibility of peripheral revascularization by angioplasty (PTA) or bypass grafting (BPG) in diabetic patients with critical limb ischemia (CLI). Some 344 diabetics were admitted because of CLI in a total of 360 limbs. PTA was performed in 308 (85.6 percent) limbs, and BPG was performed in 40 (11.1 percent) limbs in which PTA was not feasible. Revascularization could not be carried out in 12 (3.3 percent) limbs due to the lack of target vessel (9 limbs) or high surgical risk (3 limbs). BPG was considered anatomically feasible in 180 (58.4 percent) of the 308 limbs that underwent PTA. Therefore, considering also the 40 limbs that underwent BPG, surgical revascularization was judged anatomically possible in a total of 220 (61.1 percent) limbs. At 30 days, 19 (5.3 percent) above-the-ankle amputations were performed: 8 (66.7 percent) amputations were performed in the 12 non-revascularized limbs, 8 (2.6 percent) amputations were performed in the 308 limbs treated with PTA and 3 (7.5 percent) amputations were performed in the 40 limbs treated with BPG.


Researchers held a study to compare the outcomes of local injection of platelet-rich plasma (PRP) and corticosteroids in the treatment of plantar fasciitis, involving 60 patients treated conservatively for at least three months and who had no response to conservative treatment modalities. Local injection of 2 mL of 40 mg of Methylprednisolone with 2 mL of 2 percent prilocaine (metilprednizalone) was administered to the first 30 consecutive patients. The second 30 patients were treated by injecting 3 mL PRP following injection of 2 mL of 2 percent prilocaine. Patients were assessed according to the modified criteria of the Roles and Maudsley scores and visual analog scale (VAS) prior to injection and three weeks and six months after injection. The average VAS heel pain scores taken six months after treatment were 3.4 in the steroid group and 3.93 in the PRP group, and the scores in both groups were significantly lower in comparison with pretreatment levels. No significant difference between steroid and PRP groups in VAS scores and modified criteria of the Roles and Maudsley scores measured at 3 weeks and 6 months was observed.

Practice Management

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Researchers polled directors from 68 medical and osteopathic licensing boards, and in a research letter published in the Journal of the American Medical Association they note that most state medical licensing boards have reported cases of "physician violations of online professionalism." The authors determined that inappropriate online patient communications or sexual misconduct were disclosed to the boards at 69 percent of the 48 boards responding, while 63 percent reported instances of inappropriate practices such as online prescribing for patients they did not have an established clinical relationship with, and 60 percent reported cases of online credential misrepresentation. "Our findings highlight the need to promote physician understanding and self monitoring of online professionalism and to create consensus-driven, broadly disseminated principles to guide physicians toward high-integrity interactions online," the authors wrote.


MGMA Health Care Consulting Group principal Kenneth Hertz offers a number of strategies to assist in the management of teamwork and group dynamics among physicians, the first being to ensure that there are open lines of communication. Hertz notes that "it is a practice manager's responsibility to facilitate communication through meetings and informal social events; and the more communicative a group is, the easier it is to manage the dynamics." A second recommendation is to consider the use of a personality test to gain a better understanding of a practice's physicians so that interpersonal communication and activities can be customized more to different personality types. Hertz also suggests setting ground rules at meetings, while clear expectations should be developed and communicated. Another strategy is to develop a code of conduct and get it accepted by the group, while a final recommendation is the practice of introspection.


A U.S. Department of Education literacy evaluation of over 19,000 Americans found that almost 90 percent of U.S. adults are not proficient in reading, understanding, and acting on medical information, and separate toolkits released by the American Medical Association and the Agency for Healthcare Research and Quality recommend steps that physician practices should follow to help low-literacy patients. Those steps include having appointments scheduled by people rather than machines, helping patients get ready for visits by having them bring in medications and a list of questions, the use of clear and easy-to-follow signage in the office, and encouraging patients to ask questions of doctors, nurses, and office staff. Also advised is the use of patient-education materials written at a sixth-grade level or below, and communicating important information to patients orally, with video or pictures. Additionally, practices should aid patients referred for tests, procedures, and consultations by reviewing instructions and supplying transportation directions, as well as provide them with information about literacy and other nonmedical support programs. According to health literacy experts, the most critical step doctors should take is to use the teach-back technique, with the underlying concept being to ask patients to repeat back key points they need to comprehend before they leave the office.

Health Policy and Reimbursement

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A measure that would repeal the Independent Payment Advisory Board and create federal malpractice liability limits has passed the House of Representatives by a vote of 223-181. Opposition from Democrats and some Republicans critical of moving the medical liability issue from the state to the federal level was expected to result in a close vote. However, only 10 Republicans opposed the bill, while seven Democrats supported it. The outlook for the bill in the Senate is uncertain, although some Democratic senators said they would consider supporting repeal of the Medicare board. The malpractice overhaul provisions, which included a first-time nationwide cap on noneconomic damages, have particularly drawn Democratic criticism over concerns that it would limit the ability of patients to receive compensation for suffering stemming from providers' clinical mistakes.


The new Physician Payments Sunshine Act, part of the federal Patient Protection and Affordable Care Act, will require the Centers for Medicare & Medicaid Services (CMS) to publish annually the payments made to physicians and teaching hospitals by group purchasing organizations and medical manufacturers. Under the law, companies must start reporting to the CMS by March 31, 2012, though a proposed rule was not published until Dec. 19, 2011. Officials now intend to issue a final rule before the end of 2012 and launch the program by March 2013. Few organizations have been affected by this delay, as most of them already considered the issue too complex and too uncertain to deal with until details are finalized.

Many providers hope that federal officials amend some regulations before they take effect. Some organizations are concerned that the proposed rule only allows 45 days for providers to review company submissions about them. One significant uncertainty in the law is whether healthcare companies can design necessary compliance systems within the time provided in the draft rule. Despite uncertainties, industry consultants have urged providers to review recordkeeping and implement systems that would allow them to track any industry payments or gifts, which fulfill the basic requirements in the law. Preparing for the law's implementation also involves preparing the public for the release of payment information. This would involve providing "context" to explain the nature of many payments and the need for physician and industry interaction.

Medicine, Drugs and Devices

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Republicans Sens. Jeff Merkley of Oregon and Chuck Grassley of Iowa, together with Democrats Michael Bennet of Colorado and Herb Kohl of Wisconsin, have crafted the Ensuring Safe Medical Devices for Patients Act, a Senate bill that would arm the FDA for stronger oversight of medical devices while also pushing it into action. The legislation would require the agency to issue a final Unique Device Identifier (UDI) rule by the end of 2012 and add medical devices to the its Sentinel postmarket surveillance initiative. Safety problems and recalls of certain medical devices—an average of 700 recalls each year since 2005, and close to 5,000 device-implicated deaths in 2009 alone—have called into question whether the FDA and its Center for Devices and Radiologic Health have the tools needed to protect patients and keep harmful devices off the market.

Credentialing/Privileging

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When a proctor is a medical staff member who serves on a peer review committee, he or she is protected from judgments or damages by the immunity provisions of the Health Care Quality Improvement Act. Individual state peer review and business laws often add further legal protection. When the proctor is not a member of a peer review committee, and perhaps not even a member of the medical staff, an authorized peer review committee should make a formal request that he or she perform the review. Document this request in the committee’s minutes. In addition, a written agreement between the hospital and the proctor should outline the following:

* A listing of the requested proctoring duties, along with documentation that they are peer review activities authorized by the medical staff
*The terms of compensation
*The type of information/report that is expected from the proctor
*Documentation of the confidential nature of the task
*Any indemnification guarantees provided by the hospital