News From ACFAS

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Gain extensive knowledge in the forefoot surgery arena while learning practical solutions for success at ACFAS’ interactive "Forefoot Reconstruction and Complications" program presented by ACFAS Coming to You.

Case studies are shared on Friday evening following a presentation on “Common Forefoot Surgical Complications: How to Deal with Them." Then continue the dialogue on Saturday by participating in a full day of hands-on workshops and lectures. Throughout the whole program, take advantage of the opportunity the small group sessions allow to engage in lively discussion with faculty and your fellow attendees, gather feedback and learn new ideas and techniques.

To register for an Advanced Forefoot Surgery program near you, visit acfas.org/comingtoyou.
Join your colleagues this fall for one or both of two weekend ACFAS Surgical Skills Courses: Comprehensive Rearfoot Reconstruction (October 24–25, 2014; Jersey City, NJ) and Trauma of the Foot and Ankle (November 8–9, 2014; Aurora, CO, 15 minutes from Denver International Airport). Each intensive program introduces you to the latest approaches and surgical techniques in an interactive state-of-the-art learning environment. Engage in didactic lectures with expert faculty members and refine your skills in a hands-on surgical laboratory, where 80 percent of course time will be spent.

For more information on these courses and to register, visit acfas.org/skills. Attention new ACFAS Resident Members: Want to get the most out of your ACFAS Membership? Mark your calendars for the complimentary webinar Maximizing Your ACFAS Resident Membership set for August 19, 2014 at 8pm CDT, to help answer the many questions you may have regarding your new membership in ACFAS.

Want to know how to access the ACFAS website and what’s there for you? Want to know about JFAS, Scientific Literature Reviews, e-Learning opportunities, fellowships and more? Join Eoin Gorman, DPM, PGY-3 at Columbia St Mary’s Hospital, and Corey Fidler, DPM, PGY-3 at Washington Hospital Center as they go through many of the questions new resident members have and show you how to take advantage of all ACFAS has to offer. After the webinar, there will be time for Q&A as well.

Save the date, and watch your e-mail for more information on registration as the date gets closer.

Foot and Ankle Surgery

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The Food and Drug Administration (FDA) is taking a multi-pronged approach to addressing the problem of surgical fires, which can begin when electrosurgical tools ignite concentrated oxygen or alcohol-based antiseptics. For instance, the agency is working with 28 organizations to raise awareness about the issue. The FDA is also working with a number of organizations to reduce the number of such fires, which occurred about 240 times a year between 2004 and 2011, according to the ECRI Institute. The FDA has already been promoting its Preventing Surgical Fires Initiative, which includes recommendations for the safe use of surgical equipment. Efforts are also underway elsewhere to help reduce the number of surgical fires. Hospitals, particularly those that have experienced surgical fires, have taken steps such as banning the use of alcohol-based antiseptics and ensuring that saline water is on hand during procedures where the risk of fire is high. One hospital system that has been particularly successful in addressing the issue of surgical fires is Christiana Care Health System in Newark, Del. The system has not seen a patient burned in a surgical fire since 2003, when it implemented a process that includes having the surgical team discuss the risk of fire before an operation takes place.


A new study has found that a modified Broström procedure is effective at treating chronic lateral ankle instability. The study focused on 49 patients with chronic lateral ankle instability who had not been helped by non-operative management and subsequently underwent the modified Broström repair, in which the anterior talofibular ligament and calcaneofibular ligament were released from the fibula and advanced using two double-loaded metallic suture anchors. Full weightbearing using a walking boot took place the day after the operation. Follow-up was performed after an average of 42 months, at which point significant improvements were seen in post-operative Foot and Ankle Outcome Scores, pain subscale scores, symptom subscale scores, function subscale scores, and several other metrics compared to their pre-operative levels. However, three patients reported residual instability following a traumatic retear. Superficial wound infection was also observed in two patients.

Practice Management

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Physicians' practices need to be aware that several types of legal issues can impact the process of firing a physician or other provider, writes healthcare attorney Ericka L. Adler. For example, most employment contracts call for providers to be given anywhere from 30 to 120 days notice of being terminated without cause. While exercising such clauses can help a practice reduce its chances of being served with a wrongful termination suit and can help keep its relationship with the dismissed provider from going sour, practices need to be aware that they must continue to pay compensation and/or benefits to the provider during the notice period. Failing to do so can constitute a breach of contract. Another contractual clause that practices should be aware of is one that allows a provider to correct an issue that puts him or her in breach of contract. Practices may also be considered to be in breach of their contracts with a terminated provider if they fail to give the provider in question the opportunity to correct the issue that is being used as cause for termination. Finally, practices should be sure to provide the terminated provider's patients with a way to contact the provider and to arrange for those patients' records to be transferred to others in the practice. Doing so can help blunt a terminated provider's claims that his or her firing has resulted in patient abandonment.


Physicians' practices are generally overlooking three areas of potential cost savings: multi-year contracts for office leases and electronic health records (EHRs), fax machine usage, and telephone systems, writes Stephen Tramontana of the healthcare consultancy Creative Healthcare Solutions (CHS). Tramontana notes that monetary losses stemming from the failure of a doctor's practice can be reduced if practices negotiate with office leaseholders to allow them to break a 36-month lease after 12 to 15 months. Practices should also negotiate with EHR vendors to include similar provisions in their multi-year contracts, Tramontana says. He notes that EHR vendors will generally agree to such terms, meaning practices will usually have to negotiate terms for the back-end payout that are favorable to them. Tramontana also says that practices can reduce their expenses by negotiating with fax machine vendors to program the machines to only print out reports about faxes that have not gone through instead of all faxes. Practices should also insist that the fax machine print confirmations to a folder, Tramontana says. Both of these steps can help reduce expenses associated with faxing since fax machine vendors generally charge more when the number of printouts a machine makes exceeds a pre-determined limit. Finally, Tramontana says that practices can reduce their expenses by dumping traditional landline phone systems in favor of less expensive voice-over Internet Protocol (VoIP) systems.


Physicians should be careful about providing cash payments or waiving cost-sharing requirements for patients who are unable to pay for necessary care since doing so could in some cases constitute a violation of various federal and state laws. For example, physicians who treat beneficiaries of federal health insurance programs and who give these patients money or regularly dispense them of their cost-sharing obligations may be violating federal anti-kickback and civil monetary penalties laws. These laws forbid healthcare providers from making payments to induce a referral of business that is paid for by a federal healthcare program. Directly providing money to patients or routinely waiving their cost-sharing obligations essentially means that the physician is paying patients to refer themselves for additional treatment. In addition, the Department of Health and Human Services considers regularly waiving Medicare and Medicaid's cost-sharing requirements to be fraudulent activity. However, physicians who make one-time cash payments to patients or allow them to waive their cost-sharing requirements once are not likely to be singled out for scrutiny under these or other laws. Nevertheless, physicians' practices may want to consider preparing for such scrutiny by creating a charity care policy that includes guidelines for how to help patients pay for care they need. Such policies may help protect physicians from legal liability.

Health Policy and Reimbursement

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House Speaker John Boehner's office on July 10 released a draft version of a resolution that would allow the House of Representatives to sue President Obama for unilaterally delaying the Affordable Care Act's employer mandate by one year. Boehner said in a statement that President Obama essentially exercised legislative powers that he does not have in granting the delay in 2013 since the move changed the Affordable Care Act. Boehner said the delay amounted to the creation of a new law--something he said that only Congress, and not the president, is allowed to do. Both the Obama administration and the office of Minority Leader Nancy Pelosi have dismissed the lawsuit as a political stunt and a waste of taxpayers' money. The full House could vote on the resolution later this month.


The proposed Medicare Part B physician fee schedule for 2015 calls for physicians who provide Medicare beneficiaries with chronic care management (CCM) services to be required to use electronic health records certified to at least 2014 Edition meaningful use requirements. Under the proposed mandate, CCM providers would be required to have an EHR capable of supporting a problem list, medications and medication allergy checks, care coordination, and electronic exchange of summary of care record. Other types of health information technologies or health information exchange platforms that include an electronic care plan that is accessible to all of a practice's providers, as well as healthcare providers a patient sees outside of a practice, are acceptable as well. CMS says the proposal will help create a reliable flow of patient information between CCM providers, emergency rooms, hospitals, and post-acute care service providers. The proposal calls for CCM providers who do not meet the meaningful use requirements to be prohibited from billing Medicare for CCM services.


The Centers for Medicare and Medicaid Services' (CMS) proposed Physician Fee Schedule for 2015 calls for ending a provision in the Sunshine Act that exempts drug and medical device companies from having to report payments made to doctors for continuing medical education (CME). CMS says it is proposing a change in the rule because allowing the exemption to remain in place sends the message that the agency endorses continuing education events, even though that is not its intent. A number of experts, meanwhile, have argued that drug and medical device companies could take advantage of the CME exemption by shifting their marketing spending from direct promotional programs to CME, which in turn would eliminate the need for them to report these payments. The CME Coalition, a trade group that represents organizations and manufacturers that bankroll education events, criticized CMS' proposal by saying that doctors, educators, and commercial supporters are not prepared for a change in the policy at this late stage. The organization also believes that the proposed rule will stigmatize CME and thus discourage physicians from learning new medical science. In addition to the proposed change to the Sunshine Act's reporting requirements, the rule states that any increases in the "relative value units" used to calculate Medicare payments to physicians must be balanced by cuts in other areas. Cuts in payments to radiation therapy centers and radiation oncology services, for example, will be balanced by reclassifying equipment purchases as indirect expenses of providing care.

Medicine, Drugs and Devices

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No significant benefit is associated with using platelet-rich plasma (PRP) as part of a non-surgical treatment regime for patients with acute Achilles tendon rupture, a recent study suggests. The study consisted of two arms: a prospective group of 73 acute Achilles tendon rupture patients who were given two PRP injections within two weeks after their tendon ruptured, and a historical control group of 72 patients from a previous randomized controlled trial that also examined the use of PRP as part of a non-operative treatment regimen. Patients in the latter group received accelerated functional rehabilitation following their injuries that was the same as the type of rehabilitation used in the prospective group. No statistically significant differences were observed between the two groups in terms of average isokinetic plantar flexion strength at one or two years post-injury.


A recent study compared the outcomes seen in acute Achilles tendon rupture patients who were treated non-operatively with either a weight-bearing or a non-weight-bearing cast, in an attempt to move toward a consensus among doctors on how to treat such injuries. The study involved 84 patients who wore a weight-bearing or a non-weight-bearing cast for eight weeks. Both groups underwent muscle dynamometry testing at the study's six-month point. Patients in both groups experienced similar outcomes in terms of metrics such as the amount of time it took them to return to work, satisfaction with the results, and pain. However, patients who wore weight-bearing casts experienced less subjective stiffness at the one-year follow-up. At the two-year follow-up, 5 percent of patients in the weight-bearing group and 3 percent of those in the non-weight-bearing group had experienced a rerupture. These rerupture rates are considered to be low, and they suggest that initial non-operative management should continue to be used to treat acute Achilles tendon ruptures.


A new study has found that bracing, when used alone, is a more cost-effective secondary measure for preventing recurrent ankle sprains compared to neuromuscular training alone or a combination of bracing and neuromuscular training. The study involved 340 athletes who had experienced a lateral ankle sprain up to two months before the study began. Participants were randomized into one of three groups: a neuromuscular training group that engaged in an exercise program at home for eight weeks; a brace group that wore a semi-rigid ankle brace during sports activities for 12 months; and a combined intervention group that participated in the eight-week home exercise program and wore a semi-rigid ankle brace during sporting activities for eight weeks. The recurrence of ankle sprains and the costs of each of the different types of preventative measures were evaluated during the one-year follow-up period. The study found that the incremental cost-effectiveness ratio (ICER) of the brace group compared to the combined intervention group was roughly -$3,865, while the ICER of the neuromuscular training group compared to the combined group was roughly $424.