News From ACFAS

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ACFAS members should have received one of two important ACFAS surveys, Practice Economics or Member Insights, by email from the sender “ACFAS President” in the past month.

If you haven’t done so already, please click on the link in the email to take you to the confidential survey website. Your responses will be anonymous and only reported in the aggregate by a third-party survey consultant.

The practice survey closes on June 22, and the member survey closes on June 29. Please submit your responses soon! Results will be posted on ACFAS.org later this year.

Respondents will be entered into a drawing, and six winners will be chosen to win one of these thank you gifts of your choice:

• A new iPad
• Your 2013 ACFAS membership dues paid
• A complimentary registration for the 2013 Annual Scientific Conference in Las Vegas

In Rehabilitation Protocol, moderated by Thanh Dinh, DPM, our two panelists Michael Vaardahl, DPM and Harry Schneider, DPM discuss their similarities and differences for pre- and postoperative protocol with the following three procedures:

• Achilles Tendon Repair
• Lapidus Bunionectomy
• First Metatarsal Phalangeal Joint Fusion

Some of the key topics discussed within each of these procedures are: protocol for physical therapy regimen, shoe wear or orthotics, amount of time before the patient may bear weight and how to enhance range of motion.

Another aspect of care is determined by the patient’s age, physical health, realities of patient actions and postsurgical goals. Our panelists discuss how to assess these issues, and how best to approach patients who may need preoperative considerations given these circumstances.

Check out ACFAS’ new podcast today: Rehabilitation Protocol In May, ACFAS released a survey to all members to determine the overall opinion on the use of chemical DVT prophylaxis following foot and ankle surgery.

Completion of the survey entered you to win a $100 Amex gift card. Our lucky winner is Emanuel Willis, DPM, FACFAS.

Thank you all for your input!
Did you miss the free internet/social media webinar ACFAS released in May? No worries, we've posted it to our site so you can view it at your convenience.

Watch and learn how a typical patient searches for a podiatrist on Google and major search engines. Delve into all the elements that make up a successful practice’s marketing strategy, including web design, search engine optimization, reputation management, social media and mobile marketing.

You will learn first-hand how to:

• Maximize your brand with a dynamic practice website
• Reach on-the-move patients with a mobile site
• Optimize online visibility with local search marketing strategies
• Generate positive patient reviews to improve your online reputation
• Connect with patients and secure referrals through Facebook and blogs

Listen to this 45-minute program to learn how you can easily launch and manage a complete Internet strategy for your practice. View the link in the “eLearning” section of the ACFAS website.

Foot and Ankle Surgery

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Researchers sought to determine if a short-term rehabilitation program that addressed range of motion (ROM), functional muscular performance and neuromuscular control can improve the foot/ankle disability index (FADI), FADI-Sport, ROM, star excursion balance test (SEBT) and isokinetic torque for patients with chronic ankle instability (CAI). Nine subjects (rehabilitation group, RG) with unilateral CAI took part in the rehabilitation program for four weeks, whereas nine subjects (control group, CG) did not participate in that program. The results showed that the RG significantly increased FADI, FADI-Sport scores and ROM on the injured limb compared with the CG. Also, the RG had greater SEBT reaches and improvements in isokinetic torque compared with the CG.


The strength to failure for anatomic Broström repair via two suture anchors with push-lock system and with two bone tunnels were compared. In seven matched pairs of human cadaver ankles, the calcaneofibular ligament (CFL) and anterior talofibular ligament (ATFL) were incised from their origin on the fibula. A No. 2 Fiberwire suture was placed into the CFL and a separate suture into the ATFL in a running Krackow fashion with a total of four locking loops. In one ankle of the matched pair, the ligaments were repaired to their anatomic insertion with bone tunnels. In the other, two suture anchors were used to reattach the ligaments to their anatomic origins, and a push-lock was used proximally to reinforce these suture anchors. The ligaments were cyclically loaded 20 times and then tested to failure.

There was no difference in the degrees to failure, torque to failure and stiffness. A post hoc power analysis of torque to failure showed a power of .89 with seven samples. Power for initial stiffness was .97 with seven samples. Eleven of 14 specimens failed at either the suture anchor or the bone tunnel.


Researchers assessed the treatment of post-traumatic osteochondral lesions (OCLs) of the ankle with a four-step protocol. Thirty-eight patients with at least one MRI-documented OCL of the ankle were treated with a four-step surgical procedure that included synovectomy, debridement and microfractures of the OCL, capsular shrinkage and bracing and non-weightbearing for 21 days. Follow-up examination at an average of four years after surgery showed significant improvement of all variables compared to preoperative values (P < 0.05). Most patients rated their outcome as good/excellent. MRI scans taken 18 months after surgery documented completely repaired lesion in 27 ankles, slight bone marrow oedema with partially repaired defect in nine patients and visible defect in two ankles.

Practice Management

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For a physician's practice, an administrator or practice manager could be one of the most important hiring decisions. A wrong decision could be costly to undo, and could create discord among the rest of the staff. However, physicians can take several steps to make sure that they make a successful hire the first time. The first step is to create a "wish list" and identify what to look for in a candidate. This will involve a close look at the practice's needs, including getting input from partners and staff. The second step is to write a good ad for this position that attracts the right candidates. The third step is to get the ad into the best place possible. The fourth step is to screen candidates carefully. Once the applications are narrowed down to a certain pool, it is time for the fifth step of planning interviews. After the interviews, the practice could pay the potential candidate to spend a day there, interacting with staff and learning more about practice operations. This can allow partners to ask staff members to give feedback on the candidate. The final step is to have some kind of formal written documentation, such as a written job description with the requirements of the position, that can be used to assess the candidate once the trial period is over.


Preventing political discussions from causing conflict, legal difficulties or deteriorating morale is imperative for medical practices. Experts advise practices to develop policies that are sufficiently flexible to work beyond the 2012 Election Day. These policies should be written to avoid the appearance of focusing on a specific employee or showing preference for a political view, and their application must be consistent. Policies can be fairly extensive but not discriminatory; for instance, a dress code policy barring political T-shirts and pins can restrict nonverbal political expression. Whether political signs can be hung at desks is another issue worth considering, with consultants recommending their restriction if they are visible to patients.

Health Policy and Reimbursement

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The Agency for Healthcare Research and Quality (AHRQ) is taking steps to help doctors' offices move towards electronic prescription systems. As part of that effort, AHRQ has released a guide that includes guidance on how to implement an e-prescription system, as well as information about the tools that can be used during the implementation process. AHRQ is hoping that the guide will close the gap in the use of e-prescription systems that exists between doctors' offices of various sizes. An annual report released by Surescripts last year found that 46 percent of physician offices with just one doctor used e-prescription systems, while 55 percent of doctors' offices with six to 10 physicians did. The guide can be found here.


The Center for Medicare & Medicaid Services (CMS) has announced plans to accept applications for 2013 advanced-payment model accountable care organizations (ACOs). As of Aug. 1, the agency will accept applications for the program, which offers small hospitals and medical groups access to upfront payments under the Medicare Shared Savings program. CMS named the first five advanced-payment ACOs in April. It is expected to name another round of participants that will enter into shared savings contracts as of July 1.


A new study from the Center for American Progress found that health insurers, hospitals, physicians and other providers could cut $149 billion to $160 billion annually from the U.S. healthcare bill by deploying electronic processing and other administrative reforms. The report's authors offered a proposal for containing and reducing administrative costs by "embedding administrative simplification rules and systems in existing reform efforts, bringing together similar administrative processes (such as uniform physician credentialing and enrollment procedures) by different healthcare participants to maximize efficiency and creating a new federal office dedicated to simplifying healthcare administrative plans." The study specifically recommends integration of clinical and administrative functions within electronic health record systems and provision of financial incentives for providers that send administrative data electronically.

Medicine, Drugs and Devices

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The U.S. Preventive Services Task Force (USPSTF) has recommended that healthy postmenopausal women not take daily low doses of vitamin D and calcium to prevent bone fractures. Additionally, the panel said there is insufficient evidence to evaluate larger doses, easy to overdo with chewy chocolate supplements that can seem like candy. USPSTF also said existing research is insufficient to assess the risks or benefits of taking vitamin D to prevent cancer in adults. Some studies link higher levels of vitamin D with lower rates of several types of cancer. This latest report adds to many conflicting messages about the benefits and risks of vitamin D and calcium supplements. Some health experts do not agree with the task force recommendation and say women should weigh options with their physicians based on their own ethnicity, diet and sun exposure. It is also important to note several limitations in the studies analyzed by the government panel, including a lack of racial diversity and no accommodation for variety in nutritional needs.


Researchers have cultivated human bone from stem cells in a laboratory, a breakthrough that could potentially lead to patients having fractures repaired or even entire bones replaced with new ones grown outside the body from their own cells. Using stem cells taken from fat tissue, the scientists grew sections of fully-formed human bone a few inches long over about a month. Later this year, an Israeli biotechnology company that has been collaborating with academics on the technology will perform the first human trial of the bone growth method. "We use three-dimensional structures to fabricate the bone in the right shape and geometry," says professor Avinoam Kadouri, head of the scientific advisory board for Bonus BioGroup. "We can grow a bone outside the body and then transplant it to the patient at the right time. By scanning the damaged bone area, the implant should fit perfectly and merge with the surrounding tissue." The technique uses 3D scans of the damaged bone to construct a gel-like scaffold that corresponds with the shape, and then mesenchymal stem cells are collected from the patient's fat via liposuction and grown into living bone on the scaffold within a bioreactor. Kadouri says research also is underway to grow the soft cartilage at the ends of bones, which is necessary if entire bones are to be generated in a laboratory. Bonus BioGroup CEO Shai Meretzki says they hope to further develop the technology to supply replacements for damaged joints.


Researchers conducted an independent review of the mid-term effectiveness of the Bologna–Oxford (BOX) total ankle replacement (TAR). They retrospectively reviewed a total of 60 prospectively followed patients in whom 62 BOX TARs had been implanted between 2004 and 2008. The overall survival was 91.9 percent at a mean follow-up of 42.5 months. The mean AOFAS score had improved from 35.1 points (sd 16.6; 4 to 73) pre-operatively to 78.0 (sd 10.7; 57 to 100) at final follow-up (p < 0.01). Tibial radiolucencies < 2 mm in width were seen around 16 TARs. Talar radiolucencies < 2 mm were seen around four TARs. A total of 47 patients (78.3 percent) were very satisfied or satisfied with the outcome. Five patients required revision for functional limitation or continuing pain.


Some healthcare professionals are choosing to substitute Apple iPads or similar mobile devices for patient clipboards in order to boost efficiency and make paper and pencil-based data collection less of a burden. A frequently cited obstacle to hospitals’ support of mobile devices on a corporate network is security, reliability and cost issues. The University of Chicago Medicine deployed 115 iPads to internal medicine residents in November 2010, and they are helping residents maximize their time following the implementation of regulations that restrict their shift hours. A study was held to determine whether residents' ordering patterns changed after the mobile computing deployment, and it found that residents placed more orders earlier in the admission process, which cut delays in patient care. "It signaled that patient care was becoming more real-time as opposed to fragmented by the availability of computers or the availability of the data needed to make decisions," says Bhakti Patel at the University of Chicago Medicine.