News From ACFAS

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The latest edition of ACFAS Update hits mailboxes this week--don't miss this expanded issue filled with an exciting wrap up of ACFAS 2012 in San Antonio! Also in this issue, the first President's Perspective of the new ACFAS President, Michelle Butterworth, DPM, FACFAS, a perspective of multi-specialty practices, how to submit your research grant application for 2012, and much more. Looking to supplement your pre-surgical consults with more patient education? ACFAS has expanded its Patient Education library with a new Perioperative Patient Education CD filled with over 11 handouts on the most common surgical procedures, including:

• Achilles Tendon Disorders
• Bunion Surgery/Hallax Valgus Repair
• Chronic Ankle Instability
• Hammertoe Surgery
• Risks and Benefits of Surgery
• Post-Operative Instructions
and many more!

Each handout can also be tailored to your patients' specific needs!

To see a complete list of topics and to order your CD, visit acfas.org/perioperativecd.

Foot and Ankle Surgery

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Researchers employed stress ultrasonography to quantify the change in anterior talofibular ligament length during anterior drawer and ankle inversion stress tests administered to subjects with chronic ankle instability (CAI), those with a history of ankle sprain without chronic instability (coper), and healthy subjects. Sixty subjects were divided into three groups of 20. The Foot and Ankle Ability Measure (FAAM) was also used to measure self-reported function on activities-of-daily living (ADL) and sports. The length changes was greater in the CAI and coper cohorts versus the control group with both anterior drawer and inversion. There was no difference in length changes for the CAI and coper groups with neither tests. The CAI group had lower FAAM-ADL and FAAM-Sports scores in comparison to the control and coper groups.


Researchers conducted a retrospective study to evaluate the results of an intra-articular opening wedge osteotomy of the distal medial tibia (plafondplasty) for intra-articular varus ankle deformity associated with osteoarthritis and ankle instability. Nineteen plafondplasties in 19 patients were assessed over a mean period of 59 months, Lateral ligament reconstruction was done at the time of the surgery in 18 out of the 19 patients. The radiographic parameters showed no statistical significant improvement when compared pre- and postoperatively. The varus ankle tilt deformity improved from 18 degrees preoperatively to 10 degrees postoperatively (p < 0.05). The pre- and postoperative AOFAS score improved from 46 to 78 (p < 0.05). Two patients underwent ankle arthrodesis at 7 and 36 months, and two patients underwent ankle replacement at 30 and 48 months following the index procedure. Of the remaining 15 patients, 14 reported stable or very stable ankles, and 15 of the 19 were either satisfied or very satisfied with the outcome of treatment.


Researchers conducted a study to determine the effect of the defect size of osteochondral lesions of the talus (OLTs) on stress concentration, rim stress, and location of peak stress and whether a threshold defect size exists. Progressively larger medial OLTs were created (6, 8, 10, and 12 mm) in 8 fresh-frozen cadaveric ankle joints. With a calibrated Tekscan pressure sensor in the tibiotalar joint, an axial load of 686 N was applied, and pressure was recorded in neutral and 15° of plantar flexion with each defect size. The distance between peak stress and defect rim was significantly decreased with increasing defect size for lesions of 10 mm and larger. Total tibiotalar contact area was significantly decreased with increasing defect size and with ankle plantar flexion. While peak joint stress and peak rim stress were not affected by defect size or plantar flexion, average rim stress was significantly increased by plantar flexion.

Practice Management

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Hospitals seek to net well-insured patients through strategies that include buying or launching medical practices, which a new study published in the April issue of Health Affairs warns could drive up costs as well as endanger independent physician practices. The main concern of the study, carried out by the Center for Studying Health System Change's Emily Carrier and colleagues, is not what happens to independent medical practice, but the hospital expansion's overall impact on the quality and cost of patient care. Hospital administrators informed the study authors that their expansion campaigns have broadened access to care, enhanced its quality, and improved its efficiency. However, employers and insurers caution that by installing new buildings and practices in wealthy outlying areas, growth-minded hospitals will raise the cost of care in several ways. The cost of growth will be passed on to insurers and patients in the form of higher prices, while larger cohorts of hospitals and doctors will have greater leverage in negotiating contracts with payers. Hospitals claim higher costs only mirror the higher-quality care they provide to new patient populations. Carrier and colleagues also warn that hospitals that bet on affluent suburbs may let their facilities in poorer urban areas go to seed, making care less accessible in those communities.


Small changes at a medical practice can go a long way toward boosting efficiency and productivity. If the practice is unsure of how to begin implementing such changes, assessment tools can assist. Ascertaining how the practice's staffing compares to similarly sized and specialized practices can help a practice understand where it falls on the spectrum of being heavy or light on the staffing side and whether or not the right people are in the right places. A flow chart of an office and the activities that transpire in each area can identify where, when, and why inefficiencies happen.

Following a paper trail is another way to identify inefficiencies in the practice's workflow. The acquisition of new technologies, such as online portals, are an efficiency-boosting measure. If a portal does not align with the practice's goals, then adding software that links to its website and supports similar services may be more feasible. Examples of online tech tools that a practice might consider deploying include appointment bookings, lab or test result postings and/or notifications, prescription renewal requests, medical history information forms, secure messaging, and billing, insurance, and registration information updates.

Efficiency improvements also can be realized by more fully utilizing staff members, and one way to do so is through time checks. Staff cross-training will allow staffers to fill in for absent personnel quickly and easily, as well as eliminate redundancies. Having small groups of staffers meet briefly at the start of the day to discuss the schedule and identify what each can do to keep practice operations running smoothly can better enable employees to work productively despite unexpected day-to-day issues. Holding meetings with doctors and supervisors to ensure everyone is on the same page in terms of the line of authority can also help address inefficiencies.


All medical practices will soon be mandated to train staff to use revised labels and safety data sheets for potentially hazardous chemicals in products that include cleaning agents such as bleach, disinfectants, and glass cleaners and substances used for local or general anesthesia, as dictated in a new rule for hazard communication issued by the Occupational Safety and Health Administration (OSHA) on March 20. The rule's objective is to have the labels of hazardous chemicals and the safety data sheets of manufacturers uniformly display information as to whether a substance is a skin irritant, a carcinogen, a poison, or a narcotic or has some other detrimental effect. Training must be provided by Dec. 1, 2013, and can be performed by a staffer using OSHA materials or a specialty consultant. Makers of chemicals have the option of providing labels and safety data sheets in the new or old format, although only the new format can be used as of June 1, 2016.

Health Policy and Reimbursement

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The Centers for Medicare & Medicaid Services (CMS) has posted an 11-page list of corrections to its Stage 2 proposed rule on meaningful use. The CMS notice "corrects technical and typographical errors in the proposed rule entitled 'Medicare and Medicaid Programs; Electronic Health Record Incentive Program—Stage 2.' " The proposed rule was made public in February and officially published in the Federal Register on March 7. A final rule is expected to be issued this summer. The list of corrections can be found here.


Funding announcements from the Patient-Centered Outcomes Research Institute (PCORI) are expected in May, according to an April 18 article in the Journal of the American Medical Association, authored by PCORI's leaders. The projects chosen for the first round of funding will cover a wide range of clinical interventions and conditions, and will engage a number of different stakeholders, the authors said. At the same time, PCORI will begin convening multi-stakeholder conferences, workshops and advisory panels to consider whether specific research areas within each priority may be particularly aligned with PCORI criteria and deserving of more targeted PCORI funding.


The Alliance of Specialty Medicine is joining other hospital organizations to protest the proposed Medicare Reporting and Returning of Overpayments rule, which calls for providers and suppliers to return overpayments within 60 days after they are identified. The rule, called for in the Patient Protection and Affordable Care Act, was released by Medicare in February and contains provisions that the Alliance calls "onerous and unnecessary." In a letter to Center for Medicare & Medicaid Services (CMS) acting Administrator Marilyn Tavenner, the Alliance wrote that the rule would require fee-for-service providers to retain documents for four years longer than current Medicare requirements. The letter proposed reducing the overpayment-liability period to three years from the current 10 years. The Alliance also said that CMS does not clearly define when the 60-day repayment window begins. In its letter, the Alliance recommends that the window start at the conclusion of a review confirming overpayment, not the first day a possible overpayment is pointed out to a provider. The American Hospital Association and the Federation of American Hospitals have also spoken out against the proposed rule.

Medicine, Drugs and Devices

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According to Professor Hiroshi Takayanagi, of Tokyo Medical and Dental University, and colleagues, a protein produced by bone cells could help in the development of better treatments for osteoporosis. Takayanagi hopes the discovery will lead to better treatment for osteoporosis, arthritis, or bone fractures. The team found that bone forming cells, or osteoblasts, produce a protein called semaphorin 3A (Sema3A), which has previously been known to regulate nerve and immune cells. Their findings show that not only does Sema3A decrease bone breakdown but it also boosts bone formation at the same time. In the study, the team checked the activity of proteins produced by osteoblasts from mice genetically engineered to have no osteoprotegerin, and found they were still inhibiting bone breakdown. They identified the responsible molecule as Sema3A, and then they tested mice genetically engineered to have no functional Sema3A and found an increase in bone breakdown and a decrease in bone density. Surprisingly, however, they also found that bone formation was also lower in these Sema3A knockout mice. In a final experiment, the team determined that injections of Sema3A into diseased mice prevented further bone loss in osteoporosis and accelerated bone regeneration in the case of fractures. Takayanagi explained that while many molecules regulate either resorption or formation, Sema3A is the first to regulates both simultaneously. According to Dr. Gethin Thomas of the Muscoskeletal Genetics Group at The University of Queensland Diamantina Institute, this is an exciting discovery that could lead to very helpful drug developments.


The Association of American Medical Colleges has revised the Medical College Admission Test to include two new sections: one on social and behavioral sciences and a second on critical analysis and reading. The association hopes that this new testing will help future doctors improve their bedside manner by understanding people as well as science. The new test will be first administered in 2015. Researchers are still unsure whether this kind of testing can improve empathy in medical students. Pre-med students will also have to find ways to incorporate the added material into their studies. Some experts have said that the MCAT is a hindrance to producing more caring doctors, as it selects for calculation skills rather than empathy. The new, redesigned MCAT will include questions about social mobility, gender and cultural influences on expression, and how people process emotion. The use of psychology, sociology, and critical thinking on the MCAT could prompt science majors to think more about issues such as the perception of pain, informed consent, and research ethics.