News From ACFAS

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Attend the Diabetic Foot and Ankle Surgical Symposium in Miami, Oct. 26-28, to learn about core surgical approaches and procedures, including the latest cutting-edge approaches in treating the diabetic patient’s foot and ankle.

The program will offer a vast array of topics to explore and debate. Plus, take advantage of the optional wet lab workshop for an additional fee. A faculty of dedicated physician experts will lead the discussions to enhance your knowledge on diabetic foot and ankle surgery. Learn from these experts as they share first-hand their cases and experiences related to how they tackle diabetic controversies.

Additional topics covered during the symposium include:

• Perioperative Management for Limb Preservation Surgery
• Charcot Foot and Ankle Surgery
• Principles of Diabetic Foot and Ankle Surgery
• Surgical Treatment of Infection
• Plastic Surgery (Flaps) for Limb Preservation
• Forefoot Ulcer Surgery
• Midfoot and Heel Amputations
• Equinus Surgery

To read more or to register, visit the Diabetic Foot and Ankle Symposium page.
Open communication between you and your patients and potential patients by downloading the Summer Edition of the FootNotes newsletter.

Inside this issue:
Lawnmowers and Feet Don't Mix
Love Those Flip Flops?
Protect Your Feet From Skin Cancer

Remember, FootNotes is a customizable newsletter available free to all members. Send it out with your bills, put copies in your waiting room, add it to your website/blog or use it as a handout at the local health fair.

Download the Summer Edition through the web link below or by clicking here. The ACFAS Fellowship Committee recently met and reviewed another Foot and Ankle Surgical Fellowship Program:

Foot & Ankle Care Reconstruction Fellowship
Piscataway, NJ
Fellowship Director: Shail Patel, DPM, FACFAS
Click here to learn more!

This Fellowship exceeded the minimal requirements for recognition by ACFAS, but has not yet had a Fellow matriculate through the program. Thus the Fellowship Committee has agreed to grant this program “Conditional Status” for its first year. Once the first year is complete, the program will be reconsidered for full “ACFAS Recognized Status."

ACFAS highly recommends the continuation of foot and ankle surgical education after residency in the form of a specialized fellowship. Programs meeting minimal requirements are officially recognized by the College, which will in turn provide support for these programs. For a complete listing of programs, support by ACFAS and minimal requirements, please visit our Fellowship Initiative page.

Foot and Ankle Surgery

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Results of modified oblique diaphyseal, or proximal Ludloff (n = 30), osteotomy with modified distal linear, or distal Bosch, osteotomy (n=32) by a single surgeon in moderate to severe hallux valgus were reviewed and compared. AOFAS score, satisfaction rate and radiographic parameters at two years followup were evaluated. AOFAS scores were equivalent with comparable satisfaction rates in both groups, while the Bosch exhibited significantly better radiographic results, including hallux valgus angle, intermetatarsal angle, sesamoid position, and change of sesamoid position. Hallux valgus angle correction and shortening of the first metatarsal were not significant with the numbers available. Recurrence developed in eight feet of the Ludloff group and two of the Bosch group. Dorsiflexion malunion transpired in four feet in the Bosch group, versus one in the Ludloff group.


A study was held to assess the rate of recurrence, reulceration, new episodes of foot osteomyelitis and the duration of postoperative antibiotic treatment in a prospective cohort of 81 diabetic patients who underwent surgery for osteomyelitis. Forty-eight patients underwent conservative surgery, 32 had minor amputations and one had a major amputation. Reoperation was required in 20 patients due to persistent infection. Postoperative antibiotic therapy over a median period of 36 days was provided. Wound healing was accomplished by secondary intention for a median of eight weeks, and 65 patients were available for follow-up after healing. Respective percentages of recurrence, reulceration, and new episodes of osteomyelitis were 4.6 percent, 43 percent and 16.9 percent. Death during follow-up, excluding in-hospital fatalities and patients lost to follow-up, was 13 percent. There was a low rate of osteomyelitis recurrence following surgery for the condition, and despite new episodes, the researchers were able to salvage 98.8 percent of limbs.


A systematic review of surgical treatment options for osteochondritis dissecans of the talus and their stage-dependent results was held. The review included 54 studies with clinical follow-up of 1,105 patients, following application of study-specific inclusion criteria, including a minimum follow-up of 12 months and patient assessment by standardized scoring systems. The Coleman Methodology Score was used to systematically analyze the methodology of the studies, while outcome and success rate was evaluated in dependence of surgical treatment applied and in dependence of the stage of disease. All 54 studies were classified as evidence level IV representing case series, with the average Coleman Methodology Score being 63 points. Forty-seven months was the average follow-up of the 1,105 patients, with average patient age being 29 years. The proportion of good and excellent treatment outcomes was stage-independent in 75 percent of cases. The general percentage of good and excellent clinical results in 869 patients was 79 percent according to the criteria of the score applied for patient's assessment in the individual study, and was 82 percent in stage I, 86 percent in stage II, 83 percent in stage III, and 76 percent in stage IV according to the classification of Berndt and Harty.

Practice Management

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When developing reminder and recall systems, medical practices must first determine which methods are the most effective at getting patients to keep appointments or take their medications as directed. Different solutions may be required for different situations, and it may take multiple tries before the practice finds the most effective solution. "Unfortunately, there’s no simple answer, because some strategies that will work in an older population will not work in a younger one," said John Brewer, president of MedTech-USA, which helps practices comply with the Health Insurance Portability and Accountability Act. He added, "It depends on the physician’s client base."

While emails and social media are used more for general practice information, most practices send appointment reminders by phone, often 24 to 72 hours before a visit. In many cases, automated services are becoming popular as a cost-effective option, but medical practices could find more success with personal calls from staff members. According to a study published in the June 2010 American Journal of Medicine, 23.1 percent of patients who were not called did not show for their appointments. That number fell to 17.3 percent if they received a reminder from an automated call, and it further declined to 13.6 percent when a staffer called.

When no-shows are especially costly, such as for a nuclear imaging procedure, it may be better for office staff to make a personal reminder call to the patient. Some practices send snail-mail reminders for patients to make appointments, and other practices send texts. "Patients are also consumers," said Lucy Mayhugh, director of practice operations for Rush-Copley Medical Group in Aurora, Ill. "They have options, and we have to take advantage of the technology that’s available." However, many practices with older patient populations choose to forego texting reminders. When choosing the approaches they use for reminders, medical practices must remember legal issues, such as HIPAA. Communication by phone or text message requires a balance between triggering a patient response and patient privacy. Only the intended recipient should receive the reminder message, with information kept as non-specific as possible.


When problem patients arise, dismissal is a drastic step that most doctors are loath to take. However, there are some patients that go beyond disruptive, meaning dismissal is the only reasonable course of action. While dealing with tough patient problems is part of being a good doctor, there are some things that physicians and practices should not tolerate. Still, many physicians suffer through repeated unpleasant encounters without taking any action. In these cases, however, not only will failing to discharge the patient cause the physician stress and potentially endanger the patient, it could also cause some serious legal issues in the future. If all good-faith efforts on the part of the physician to maintain the relationship fail, they should not be afraid to take action to discharge the patient.

Some of the key scenarios in which discharging the patient may be necessary are when a patient is dangerous, threatening or abusive; fraudulently uses controlled substances; files a lawsuit; refuses to follow recommended medical treatment; frequently misses appointments without notice; repeatedly fails to pay bills despite his or her ability to pay and/or your efforts to provide him or her with a suitable payment plan. It is best to have a patient-dismissal policy in place that an attorney has reviewed, and dismissal should be a "last resort." There are also ethical considerations to dismissal, and physicians should always do their best to make it work. When a patient's behavior does not change despite efforts and warnings, then severing ties may be the last option.

There are guidelines on the timing and process of patient dismissal, and not following these principles may lead to a lawsuit or complaints to the state medical board. Physicians would be wise to seek counsel with an attorney to help develop a dismissal policy, and it may also be a good idea for them to contact their professional liability carrier to determine its policies and recommendations. In the event of a dismissal, everything must be documented in the patient's chart so that the reason for dismissal as clear as possible.

Additionally, all staff members should be notified and instructed on how to handle any contact initiated by a dismissed patient. Another good policy is to identify one staff member to handle all of the discharged patients' questions, requests and complaints. Finally, the patient should be notified of his or her dismissal via a dismissal letter, which should include the reason for dismissal, record release information, referral guidance, and information regarding the notice period. In general, the dismissal process and the dismissal letter should remain consistent regardless of the reason for termination. The final step is to send the patient a copy of his or her medical record.

Health Policy and Reimbursement

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The Center for Medicare & Medicaid Services (CMS) is using a two-pronged strategy to cut down on fraudulent claims as part of an effort to meet requirements set forth in the Small Business Job Act of 2010. CMS is hoping to prevent fraudulent payments from being made by using a predictive modeling system that consists of a fraud prevention system from Northrop Grumman and an automated provider screening system from Rockville, Md.-based TurningPoint.

Northrop Grumman's fraud prevention system uses predictive technology to look for the presence of suspicious billing patterns in real-time. Any claims that contain suspicious billing patterns are then evaluated. The automated provider screening system, meanwhile, uses credit histories, credit scores and other information to develop a risk score that measures the likelihood of a provider being fraudulent.


A group of doctors is suing Virginia over a provision in its heathcare law that forbids medical professionals from offering certain new services or purchasing certain types of equipment without first getting an official go-ahead from the state Department of Health. The lawsuit, filed Tuesday in federal court in Alexandria, charges Virginia with violating the Commerce Clause of the U.S. Constitution, the same charge the state is leveling at the federal government in requiring most Americans to purchase health insurance or face a penalty. Plaintiffs in the case against Virginia argue that they are not able to import goods like MRI machines or CT scanners via interstate commerce because of Virginia’s “certificate of need” requirement for pre-clearance of new services or equipment with the state Health Department.

Medicine, Drugs and Devices

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A study published in the journal Pediatrics found that putting children's photos in their electronic hospital charts could help lower the likelihood of misplaced orders, in which a child receives care intended for another patient. Such a practice was tested at Children's Hospital Colorado, which led to the incidence of misplaced orders being reduced from 12 in 2010 to three in 2011. Meanwhile, the number of "near-miss" cases, where a treatment or test was ordered for the wrong patient, but another staff member caught it in time, fell from 33 to 10 over the same period. Lead study researcher Daniel Hyman with Children's Hospital Colorado says it is feasible for other hospitals to add photos to their electronic records, and his hospital accomplished this by using digital cameras to take pictures of children as they were admitted.


Physicians who own tablet computers such as iPads are using them in the workplace in creative ways. According to Manhattan Research’s “Taking the Pulse U.S. 2012” survey of 3,015 physicians in 25 specialties, physician use of tablets is growing fast. The survey found that 62 percent of physicians owned a tablet computer, an increase from 27 percent in 2011. Half of that 62 percent use them at the point of care. In comparison, about 50 percent of physicians are using electronic health records (EHRs).


The Food and Drug Administration, the Centers for Disease Control and Prevention's National Institute for Occupational Safety and Health, and the Occupational Safety and Health Administration issued a joint safety communication recommending usage of blunt-tip suture needles to lower the risk for needlestick injuries and potential subsequent bloodborne pathogen transmission to surgical staff. The advisory says blunt-tip suture needles, "which are not as sharp as standard (sharp-tip) suture needles, are designed to penetrate muscle and fascia and reduce the risk of needlesticks." There are approximately 384,000 annual needlestick injuries in hospitals, 23 percent of which occur in surgical settings, according to the alert. More than 50 percent of needlestick injuries involving suture needles take place during the suturing of muscle and fascia, and the risk of such injuries may be reduced by more than 66 percent with blunt-tip suture needles.


London surgeons are testing touchless technology, frequently used in TV games, in the performance of keyhole surgery so that they have more control over operations, less disruption and less likelihood of contamination. The system lets doctors manipulate images with their voice and hand gestures instead of using a keyboard and mouse, and independent experts say this method could become routine in the next 10 or 15 years. Microsoft Research developed the refinements that allow the gaming technology to be used for surgery, with support from Lancaster University. St. Thomas' Hospital vascular surgeon Tom Carrell attests to the technology's ease of use, noting that "the sensitivity is the main thing, but it's very simple gestures, like on a smartphone. Once you know the gestures it's very intuitive."