News From ACFAS

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It's easy to submit your scientific poster for presentation consideration at the 2014 Annual Scientific Conference in Orlando, FL. Visit acfas.org to submit your paper, and be sure to carefully read the full 2014 Poster Exhibits Guidelines PDF closely before beginning your submission.

New This Year:

• Scientific Format posters accepted for presentation at the Annual Conference must be submitted in both paper and electronic (PDF) format.
• At least one of the poster authors (both Scientific Format and Case Study Format) must register for and attend the Annual Conference in order for their poster to be displayed.

If you would like your research to be considered for presentation, submit your application and abstract via the online submission system by October 15, 2013.

Manuscripts are also being accepted for oral presentation consideration at the 2014 Annual Scientific Conference. For detailed information on manuscript submission, please visit acfas.org. Be sure to read the 2014 Call for Manuscripts (Information and Policies) and Instructions for Authors Submitting a Manuscript before submitting your manuscript. Manuscripts must be submitted via the online submission system no later than August 15, 2013. Apply today to attend the Total Ankle Arthroplasty Surgical Skills Course, which takes place October 3-5 in Henderson, Nevada. This hands-on, unique skills course is taught by a faculty of foot and ankle surgeons who specialize in total ankle replacement and are ready to share their tips and lessons-learned with course participants. Earn up to 16 continuing education contact hours as you work through all-encompassing learning objectives that teach you how to surgically treat a multitude of variables within the realm of total ankle arthroplasty.

Download the entire skills course catalog to view more details about this course (pages 5-6). Enrollment is limited, so apply today by filling out the Application Form and faxing it to ACFAS Headquarters at (800) 382-8270. Every foot and ankle surgeon understands the importance of having a good set of surgical tools to be successful in the OR, but how successful is your PR? How are you marketing yourself and your practice to new patients? To help members be successful in their practice marketing efforts, ACFAS has developed a new, free Marketing Toolbox on the new ACFAS website. The Toolbox is equipped with all the marketing and public relations tools you’ll need to effectively promote your practice to existing and potential patients, plus new tools are also in development.

Some of the tools you'll find include:

• A New The Foot and Ankle Surgeon Brochure
• Media Pitch Templates & Guidelines
• Linking Your Website to FootHealthFacts.org
• How to Use Social Media to Grow Your Practice
• Fill-in-the-Blank Press Releases
• FootNotes Patient Newsletter
• PowerPoint Tools
• Patient Education CDs
• Member Logo Library

Start promoting your practice today by taking advantage of the many promotional opportunities of the new Marketing Toolbox at acfas.org/marketing. Help to build a future for foot and ankle surgery and apply for the 2013 ACFAS Scientific Research Grant. Applications are being accepted now online at acfas.org and must be submitted by September 16, 2013. This annual grant provides financial assistance to members studying topics in the field of foot and ankle surgery. Plus, new this year, the Board of Directors recently granted twice the amount of funding as last year’s with up to $40,000 in grant money to possibly be awarded!

The goal of this program is to encourage members to implement evidence-based medicine in order to advance their clinical practice and to help better serve patients. The research must be clinical or laboratory-based, with clearly defined research goals meeting all the criteria for grant submission.

Again, applications will be accepted until September 16, 2013. Information on the criteria and other details regarding the grant application can be found on acfas.org, under the "Research and Publications" tab when you click on "Research Resources."

Foot and Ankle Surgery

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Researchers examined the changes in tendon structure in unilateral Achilles tendinopathy patients found that these changes are seen in both symptomatic and asymptomatic tendons. The study involved 13 unilateral Achilles tendinopathy patients with various times of symptoms whose Achilles tendons--both the symptomatic and asymptomatic tendons--were scanned using ultrasound tissue characterization (UTC). Researchers quantified tendon structure from the insertion to the musculotendinous junction using software that quantifies the stability of the echopattern and allows semi-quantification of tendon structure. A related-samples Wilcoxon signed rank test, meanwhile, was used to compare the structure of the symptomatic and asymptomatic tendon. No significant difference was seen in any of the four echo types between the symptomatic and asymptomatic tendon, though researchers did observe diffusely scattered disorganization within the asymptomatic group throughout the length of the tendon. Disorganization in the symptomatic tendon, meanwhile, was primarily seen in focal lesions that were generally characterized by echo-types representing extensive fibrillar disorganization. These findings led researchers to conclude that treatments for unilateral Achilles tendinopathy should mostly focus on improving tendon structure in both limbs.


Researchers found that PET/CT scan allows doctors to quantify the inflammatory process that is observed in stage 0 Charcot foot (CNO) patients. The study, by researchers in Italy, examined 25 diabetic patients with an acute stage 0 CNO. All of the subjects underwent an X-ray, MRI, and F-FDG PET/CT scan at baseline as well as another F-FDG PET/CT scan at clinical recovery, which was defined as being within one month after the inflammatory clinical signs of the CNO foot and skin temperature difference were less than 2 degrees Celsius compared with contralateral foot.

Additional F-FDG PET/CT scans were performed every three months until patients reached final recovery, when the standardized uptake value (SUVmax) was less than two. Researchers reported that the SUVmax of the affected feet of all patients was higher than that of the contralateral foot at baseline, and that signs of inflammation were no longer seen at clinical recovery. SUVmax remained unchanged between baseline and clinical recovery, though SUVmax did drop between clinical recovery and final recovery.


Researchers in Germany have performed a study to determine whether the electrical stimulation threshold for a motor response of the sciatic nerve is higher in diabetic foot gangrene patients than it is in individuals without diabetes. Participants in the study included patients about to undergo surgery to treat diabetic foot gangrene, as well as non-diabetics about to undergo orthopaedic foot or ankle surgery who did not show any risk factors for peripheral neuropathy. The study found that the geometric mean of the motor stimulation threshold was higher in diabetics than it was in non-diabetics. The geometric mean of the electrical stimulation threshold for a motor response of the sciatic nerve was higher by a factor of 7.2 in diabetics compared to non-diabetics. Researchers concluded that this higher electrical stimulation threshold could negatively affect nerve identification in diabetic foot gangrene patients.

Practice Management

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A number of healthcare reform measures are putting doctors' practices under a growing amount of pressure to review their revenue cycle operations, says Nancy Ruff, the director of health advisory services for the Dallas-based consultancy CTG Health Solutions. Perhaps the most important of these changes, at least with regard to a practice's revenue cycle operations, is the impending implementation of ICD-10, Ruff says. She notes that practices that currently do not have efficient revenue cycle operations, as well as those that have not updated their technologies or do not have good coders in place, "should be very concerned about what to do next and how to stay ahead."

Ruff says that preparing for the implementation of ICD-10 should be given the same priority as adopting electronic medical records (EMRs). Practices that work on adopting EMRs but fail to plan, test, and train for the implementation of ICD-10 on time, Ruff says, could experience a complete cash stoppage. But Ruff says that the implementation of EMRs, as well as the changes associated with the Affordable Care Act, are putting practices under pressure as well. For example, practices cannot simply focus on getting their EMR systems up and running, and instead must perform a security risk analysis that shows that the systems meet strict security standards as outlined under the law, says attorney Evan S. Schwartz. He added that most of the effects of the Affordable Care Act have yet to take place.


The sudden departure of a physician from a practice leads to disruption and declines in productivity and service levels, while replacing the physician can be extremely challenging, particularly if it has to be done quickly. The practice should consider issues raised by such a departure, such as who will see the physician's patients, whether the practice can be preserved, whether a replacement is necessary, and dealing with overhead in the physician's absence.

The practice should learn why the physician is leaving, and whether the stated reason is the actual reason for departure. The practice also should be cautious of what they say to the exiting partner if the departure is the outcome of an internal dispute. A spokesperson should be appointed to contend with the leaving staff member and his or her representatives to ensure consistency of message and avoid back-channel dialogue by a rogue partner that could later negatively obligate the practice to retain the physician.

Practices also should contact their attorney and management adviser, who will likely advise immediate review of the practice's files. The group lawyer should brief the practice on what its obligations to the exiting member are and what his or her obligations are to the group. A review of the practice's corporate articles of incorporation and bylaws also is necessary.

Obligations the practice may have to fulfill include buying back the departing partner's interest in the practice assets, paying out vested retirement benefits and collecting the physician's accounts receivable.

The practice's written and oral promises must be crafted carefully, as the practice must meet those promises. The practice's retirement plan will specify paying out vested accounts to exiting employees or partners and the practice will need to follow it precisely, but magnanimity should not exceed the plan's mandates.


Of the thousands of physicians that routinely use a tablet computer in their work, a growing number are embracing non-iPad alternatives. Manhattan Research's Taking the Pulse U.S. 2012, a study of 3,015 practicing physicians in 25 specialties who were online demonstrated that professional tablet use almost doubled since 2011, reaching 62 percent. Dr. Scott Litton prefers the HP 2760P, a Windows 7 tablet, because it can shift into a laptop-with-keyboard mode very quickly, and because it allows him to use several applications simultaneously. Also, the Dell Latitude 10, designed with regard to Health Insurance Portability and Accountability Act and the Federal Information Processing Standards, employs dual-authentication security that requires both an integrated smart card and a fingerprint reader to access data. The ThinkPad Helix Ultrabook is praised for its versatility across tablet and laptop functions, and includes a modular keyboard, 10+ hour battery life, and 10-point multi-touch and digitizer pen functions. Blackberry's Playbook tablet receives accolades for its pocketability and its medical-imaging app. However, Apple's iOS operating system still has far more apps than any other system.

Health Policy and Reimbursement

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The Department of Health and Human Services Office of Inspector General posted an advisory opinion on June 11 about a podiatry clinic's plan to create a separate limited liability company (LLC) to provide custom orthotics to employees who work at manufacturers and other types of organizations where workers spend large amounts of time on their feet. The opinion noted that HHS does not believe that the plan would trigger anti-kickback penalties. HHS also stated that the LLC would likely avoid penalties because it has said that it planned to price the custom orthotics at fair market value rather than on volume or values of referrals. In addition, HHS said it based its ruling on the fact that the LLC would not involve suspicious "swapping" arrangements in which it would it would provide lower prices for orthotics in order to encourage customers to purchase services that it would be reimbursed for through federal healthcare programs.


The American Medical Association (AMA) and physician leaders are criticizing a ruling by the 4th U.S. Circuit Court of Appeals in a case involving the North Carolina State Board of Dental Examiners and the Federal Trade Commission. The court handed down its ruling on May 31, saying that the dental board exceeded its authority when it sent cease-and-desist letters to non-dentists warning them that they were violating state law by providing teeth whitening services at shopping malls. The court also agreed with the FTC's argument that the board is not protected from anti-trust scrutiny because it is not actively supervised by the state and because its members are private market participants. AMA President Dr. Jeremy Lazarus said the court's ruling was "deeply flawed" and that it could make it difficult for state governments to take steps to protect public health and ensure the safety of patients. Other critics of the ruling say that the court's decision could make doctors less inclined to serve on state licensing boards, make board members less likely to make tough regulatory decisions because of fears of federal scrutiny, and lead to more legislative rules that give states more oversight over the boards. The North Carolina State Board of Dental Examiners may opt to have the 4th Circuit rehear the case, or it could appeal to the U.S. Supreme Court.


The Federal Trade Commission (FTC) has criticized legislation being considered in Connecticut that would allow independent physicians to create "cooperative arrangements" so that they can negotiate payment rates with insurers together. The FTC says that the cooperative arrangements created by the bill, which is supported by doctors, would be harmful to healthcare consumers in Connecticut because they would not be subjected to certain anti-trust laws. In addition, the FTC says that the bill will likely encourage anti-competitive conduct. However, Connecticut State Medical Society President Dr. John Foley says the legislation is necessary because most doctors in the state work independently and do not have the leverage to negotiate with Connecticut's "consolidated and highly concentrated" health insurance market.


The cost to repeal the sustainable growth rate is $106 billion less than only one year ago. The Congressional Budget Office put a $138 billion price tag on the most recent 10-year score for repealing the SGR, which is $106 billion less than its 2012 score. Senator Max Baucus (D-Mont.), chair of the Senate Finance Committee, has called this a window of opportunity. One House bill has already been presented to repeal and replace the SGR, and there are three more pieces of legislation (one in the Senate and two in the House) expected to be introduced.

Medicine, Drugs and Devices

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Doctors say that a technique that uses amniotic fluid can help diabetics avoid having a foot or other extremity amputated. The technique, which was developed by Dr. Bruce Werber of InMotion Foot & Ankle Specialists, involves injecting or wrapping amniotic fluid around a damaged nerve during decompression surgery. Diabetics are at risk of developing nerve disease, which can reduce sensation in their feet and lead to the development of sores and infections that could in turn lead to amputations. But by applying amniotic fluid--which contains stem cells--to a damaged nerve, doctors can stimulate the affected area and spur the healing of wounds. Dr. Jacoby, the medical director at the Scottsdale (Ariz.) Neuropathy Institute, says he has used this technique on 16 nerves and has seen sensation return in all of them. He noted that this technique has been successful even in patients displaying Tinel's sign, or a complete lack of sensation. It was previously thought that it was impossible to save feet in which there was no sensation at all. But while the technique can help diabetics avoid amputations, Jacoby said, it will not stop or reverse diabetic neuropathy.


The U.S. Food and Drug Administration (FDA) is cautioning medical device makers that computer viruses are threatening to infect their equipment and place patients at risk. The FDA for the first time advised manufacturers to submit security plans to thwart cyberattacks when seeking approval for their products and also recommended that hospitals practice more vigilance in reporting cybersecurity failures. Previously undisclosed Department of Veterans Affairs records estimate that malware infected at least 327 devices at VA hospitals since 2009; while more than 40 viruses contaminated equipment such as x-ray machines and lab gear made by companies such as General Electric, Siemens, and Philips. Experts say such failures highlight vulnerabilities created in the scramble to digitize healthcare, which has led to an interconnected mesh of devices linked to hospital networks, which are in turn connected to the Internet. Such episodes also expose the problem of some device manufacturers' reluctance to admit to the existence of security gaps or assume the expensive job of designing more secure products. Device makers claim they cooperate with hospitals to fight computer infections and some have organized expert teams to respond to incidents.


A study published in the New England Journal of Medicine has found that Amgen's biologic rheumatoid arthritis (RA) drug Enbrel is no more effective than a therapy consisting of several generic drugs. The 353 patients who participated in the study were randomized to receive methotrexate and Enbrel or methotrexate and sulfasalazine and hydroxychloroquine. Patients who were given methotrexate, sulfasalazine, and hydroxychloroquine saw their symptoms reduced by 2.1 points on disease-activity scale ranging from two to 10, compared to a 2.3 point reduction among patients who were given Enbrel and methotrexate. Researchers concluded that since the two types of treatments had essentially the same level of effectiveness, doctors should consider treating certain RA patients with combinations of traditional drugs before treating them with more expensive biologics.