News From ACFAS

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The 2012 ACFAS Clinical and Scientific Research Grant application is now online. The grant provides financial assistance to members studying topics in the foot and ankle surgery arena that could otherwise not be funded. The goal of this program is to encourage members to implement evidence-based medicine in order to advance your clinical practice and to help you better serve your patients. The research must be clinical or laboratory-based, with clearly defined research goals meeting all the criteria for grant submission.

The ACFAS Research Committee is also encouraging use of a scoring scale, including the ACFAS Scoring Scale, which has been fully validated by a volunteer ACFAS task force. Find the Criteria, Scoring Scale, its Validation, the application and more information at acfas.org/grant.

Application deadline is Sept. 1, 2012. The ACFAS Regional Divisions will continue to support first-year podiatric surgical residents by providing complimentary first-year membership in the College. This offer provides the benefits of membership with dues waived for one year. This is a direct value of $116, plus additional savings through member pricing on conferences, products and services.

Kick-start your career with ACFAS! We connect residents to a community of your peers — the best and brightest foot and ankle surgeons in the country. You will have access to the College’s premiere website, and a subscription to the prestigious online Journal of Foot and Ankle Surgery (JFAS) — a must-have to increase your knowledge of the latest surgical techniques and research.

Applications for membership are available through the ACFAS website; joining now will provide an additional three months of membership, through September 2013 — and put JFAS in your mailbox that much sooner!

Once again, congratulations to the Class of 2012. The ACFAS Regional Divisions look forward to welcoming you to the College. Register for and attend these highly interactive programs which take place at the DoubleTree by Hilton Hotel & Suites in Jersey City, NJ:

• Surgical Solutions for Complications of the Forefoot, Friday, Nov. 2
• Surgical Solutions for Complications of the Rearfoot and Ankle, Saturday, Nov. 3

Faculty members will guide you through patient evaluation and the latest approaches and surgical techniques in a series of didactic lectures, demonstrations and the surgical skills laboratory. As you work together in the lab, your faculty will share critical insights gained through their extensive experience. There will be additional time for panel discussions and case presentations.

Register now for the Surgical Solutions for Complications of the Forefoot, Rearfoot and Ankle series! ACFAS hosts its very own private Facebook group so members of the podiatric community can share their success stories, comment on other podiatrists’ endeavors, post pictures and more!

When you log in to Facebook, type “American College of Foot and Ankle Surgeons” into the search box, and click on the option that says “Group” in the drop down menu. Near the top, right-hand corner, click “Join Group.” A request will be sent to the ACFAS headquarters and once your name has been verified, you may begin posting – it’s that simple!

Have a question, article or comment that you want to share with the foot and ankle surgical community? Post it on the ACFAS Facebook group page! Also, ACFAS shares many stories we find in the news about members. Join the Facebook group so you can see these stories and share them with your own friends. You may already be featured and not even know it! Be a part of it: join the ACFAS Facebook group today.

Foot and Ankle Surgery

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Patients with diabetes whose foot ulcers fail to heal have increased inflammation and aberrant growth factor levels. Researchers followed 104 patients with type 1 or 2 diabetes and 36 healthy controls to investigate whether vascular function and inflammation play a role in the development and healing of diabetic foot ulcers. They found that after a mean of 18.4 months, 30 patients with diabetes (29 percent) developed foot ulcers. These patients had more severe neuropathy, a higher white blood cell count and reduced vasodilation. Ulcers failed to heal in 47 percent of these patients. Compared with those who healed, these patients had higher serum levels of tumor necrosis factor-alpha, monocyte chemoattractant protein-1, matrix metallopeptidase 9 (MMP-9) and fibroblast growth factor 2. Compared with skin samples from control patients, patients with diabetes had greater immune cell infiltration, MMP-9 expression and protein tyrosine phosphatase-1B (PTP1B).


A study was performed to evaluate the results of a new neonatal clubfeet management protocol that can be considered a modification of the Ponseti technique. The modifications included executing tenotomy of the Achilles tendon before application of the first cast and using only one cast for a period of three weeks after tenotomy. The modified method was administered to 50 children, or 82 club feet, and the degree of deformity was assessed using the Pirani and the Dimeglio scoring systems. The minimum follow-up period was 28 months. The intermediate range follow-up outcomes of the study demonstrated that the modified Ponseti method corresponded with a good result in 85 percent of cases of neonatal club feet with a Pirani score of 5 or less and a Dimeglio score of 15 or less. Persistently high Pirani or Dimeglio scores immediately following tenotomy and poor compliance with splintage were predictors of failure of the modified method.


A study was held to analyze the outcomes and complications of Weil and triple Weil osteotomy used to treat third rocker metatarsalgia, using a sample of 82 patients operated on from March 2004 to May 2007. Seventy-six patients—68 women and eight men—completed the study, with a total of 93 operated feet, 52 right and 41 left. The AOFAS score was used to evaluate the clinical results for the assessment of lesser metatarsals and interphalangeal joints, and weightbearing lateral and AP foot x-ray were employed for radiological assessment. The median AOFAS score was 90, while good results were exhibited in 80 percent and unsatisfactory results in 20 percent. Seventy-five feet were index-minus before surgery, but all 81 feet were plus-minus post-surgery. Serious recurrence of metatarsalgia was observed in 4.3 percent, moderate stiffness in 60.2 percent, floating toes in 4.3 percent and delays in bone healing in 7.5 percent.

Practice Management

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Hiring new employees for a medical practice can be a challenging proposition when it comes to fulfilling intangible requirements such as alignment with the practice's cultural aspects and goals. This requires physician groups to evaluate their own cultures, ascertain their needs and identify the most important employee characteristics. The assessment of the practice's culture should encompass identifying the vision, mission and values. "Some practices are very corporate, with very strong policies and procedures. They're very structured," says Peggy Pringle with the Texas Medical Association. "There are other practices where it is very family-oriented." Practices also must consider that the culture will likely vary according to how distinct departments are from one another. "Some [doctors] are very strong micromanagers," Pringle notes. "If the employee doesn't like to be micromanaged and doesn't need a lot of direct supervision, they are going to be driven crazy."

Considering the group's needs is the next step, according to medical practice hiring advisers. A strong cultural fit means that all the people working in a specific setting cooperate. The practice cannot go in a certain direction without the appropriate combination of staff, and Gerrit Salinas with Snelling Staffing Services in Dallas says, "it's not just about which people work best with me. It's also about what's missing and what I need." Once a potential candidate has been identified, the next step involves asking him or her open-ended questions that may signal cultural alignment. For instance, if the practice prioritizes compassion, have the candidates provide examples of times they have been compassionate inside or outside the workplace.

Applicants should have at least two interviews, with additional conversations including questions about potential stress management and applicants' perception of autonomy. There does not have to be a perfect handling of cultural fit, as a new hire does not always have to be dismissed if he or she is slightly mismatched with the practice's culture. "Some people can adjust into the practice," Pringle says. "People can be brought around with coaching if it is not an extreme mismatch." Physician recruiters say doctors should consider what they feel is of value to their professional happiness, regardless of how big or small it may seem. Doctors should be ready with queries of their own, such as the practice's future plans.


Technology can make complying with the new the ICD-10 code set easier for practices. Practices should start by upgrading practice management systems, electronic health records (EHRs) and other technology to the Version 5010 standard, and then complete testing with vendors. Practice staff, such as billing managers, also have to be prepared for the ICD-10 coding transition, and there are many ICD-10 seminars and workshops offered by various groups to fulfill this requirement. In addition, technology tools such as Web- or software-based programs and CD-based slideshows are loaded not just with the latest codes, but with tips on what to consider when choosing a code. Furthermore, a practice should ensure physicians are familiarized with using their EHR so there are as few coding slowdowns as possible, so they should be provided with quick access to the ICD-10 version of the most commonly used codes. Finally, the practice should consider investing in technology that raises overall productivity, such as patient kiosks and media tablets.

Health Policy and Reimbursement

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The American Medical Association recently voted to evaluate ICD-11 as a possible alternative to ICD-10 for replacing ICD-9. The AMA said it will report back to delegates in 2013 with its findings. "It is critical to evaluate alternatives to ICD-9 that will make for a less cumbersome transition and allow physicians to focus on their primary priority – patient care," said AMA President-elect Ardis Dee Hoven, MD, in a statement. "The policy also asks stakeholders, such as the Centers for Medicare and Medicaid Services, to examine other options." AMA is not alone in its consideration of ICD-10. In a blind poll, nearly a quarter of Government Heath IT readers said that the U.S. should leapfrog ICD-10 in favor of ICD-11. While a third responded negatively to this idea, perhaps the most telling result is that even with the fact that ICD-11 is not yet finished, 43 percent of respondents said going directly to ICD-11 is worth considering.


The U.S. Department of Health and Human Services' (HHS) inspector general's office plans to revise the rules for how healthcare providers can turn themselves in for potential violations of the fraud and anti-kickback laws in order to receive quick settlements. Since 1998, the inspector general has collected more than $280 million and resolved at least 800 such self-disclosures from physicians, hospitals and other healthcare providers, according to a notice published in the Federal Register.


A new Medicare billing policy takes effect on July 1, but many physicians and practice managers are unprepared. The new policy would pay lower rates for certain services in hospital-owned physician practices; these practices must change their coding practices under the new regulation. The Centers for Medicare & Medicaid Services now requires that a hospital notify its wholly owned or operated physician practices when a patient is admitted to that hospital. Practices that treated the patient within three days before the admission must update billing forms for that patient with a special coding modifier. This indicates to Medicare that the services provided during that three-day window are to be paid at the lower facility rate. Claims already filed for that patient must be refiled by the practice with the modifier attached. Although this new policy was first scheduled for a Jan. 3 implementation, Medicare agreed to a delay to give hospitals and practices more time to establish the necessary communication channels. However, many physician practices and hospitals are saying that they still need more time.

Medicine, Drugs and Devices

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Increasingly, physicians are using new technologies with their patients: texting health messages, tracking disease trends on Twitter, identifying medical problems on Facebook pages and communicating with patients through email. Many doctors are still most comfortable using e-technology to communicate with each other, not with patients; but some physicians realize patients want more than a 15-minute office visit and callback at the end of the day. Doctors’ use of social media and virtual communication for patient care is expected to increase under the Accountable Care Act, which encourages electronic health records and the “electronic exchange” of health information.


Fourteen patient safety measures related to complications such as wrong-site surgery, medication errors and postoperative pulmonary embolism have been endorsed by the National Quality Forum (NQF). The measures were devised by the Agency for Healthcare Research and Quality, the Joint Commission, the National Committee for Quality Assurance and the Ambulatory Surgery Center Quality Collaboration, and reviewed by NQF's Patient Safety Complications Steering Committee. The new safety measures can be found here.


A study was held to compare the measurements of the hallux valgus angle (HVA), intermetatarsal angle (IMA) and distal metatarsal articular angle (DMAA) made with an iPhone accelerometer and computerized measurements as a reference in a series of 32 hallux valgus patients. Digital angular measurements on the computer were established as the reference standard for analysis and comparison. The difference between computerized measurements and all iPhone measurements and the difference between the first and second iPhone measurements for each observer were estimated. Testing of the inter- and intraobserver reliability of the smartphone measurement method also was carried out. The variability of all measurements was similar for the iPhone and the computer-assisted methods. Concordance between iPhone and computer-assisted angular measurements was outstanding for the HVA, IMA and DMAA. The maximum average difference between the two methods was 1.25 plus or minus 1.02 degrees for HVA, 0.92 plus or minus 0.92 degrees for IMA and 1.10 plus or minus 0.82 degrees for DMAA. The interobserver reliability was excellent for HVA, IMA and DMAA. The maximum mean difference between observers was 1.31 plus or minus 0.89 degrees for HVA, 0.90 plus or minus 0.92 degrees for IMA and 0.78 plus or minus 0.87 degrees for DMAA. Intraobserver reliability was outstanding for HVA, IMA and DMAA.


Researchers combined qualitative and quantitative data through sequential data analysis and triangulation to determine the interplay of factors that influence a patient's decision to wear custom-made orthopaedic shoes (OS). The qualitative segment of the analysis was assigned priority, and the qualitative data was collected with a semi-structured interview covering three domains: usability, communication and service and opinion of others. Quantitative data focused on the interplay between variables and determining a rank-order for the importance of usability factors. A patient's choice to use OS was shaped by various factors indicated as being important and by acceptance of their OS. Usability factors were more important than communication factors, while the opinion of others was of limited importance. Walking improvement was deemed the most critical usability factor. The value of other factors, such as cosmetic appearance and ease of use, was ascertained by reaching a compromise between these factors and an improvement of walking.