News From ACFAS

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Turn the new acfas.org into an “app” on your iPhone or smart phone for one-touch access to your College! With the new mobile-friendly acfas.org, it’s easier than ever to get the latest from ACFAS while on the go, and by adding a bookmark of acfas.org to your phone’s home screen, you’ll be even more connected.

To add an acfas.org bookmark or “app” icon to your home screen, follow these easy steps:

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Learn a fresh approach to the surgical management of adult flatfoot at the Comprehensive Flatfoot Surgical Skills Course (Reconstruction and Arthrodesis), November 1-2, in Denver, Colorado. This dynamic course approaches adult flatfoot reconstruction and arthrodesis with a round-robin method, as the diverse faculty rotates lab stations to give valuable tips and answer your specific questions. Participants will pioneer deep into specific surgical scenarios while working in coordination with a lab partner to achieve the best possible outcome. Take advantage of this opportunity and walk away with an increased knowledge of contemporary techniques utilized to address issues associated with flatfoot deformities, the ability to perform reconstructive procedures for stages 2-4 PTTD, and address the dilemma of stage 2 PTTD.

To register for the Comprehensive Flatfoot Surgical Skills Course or for more information, visit acfas.org/skills. Don’t forget to make the switch and "Like" ACFAS’ new Facebook Page by August 1. Remember, those who Like the new Page by making the switch from the old Facebook Group are entered into a drawing for three American Express Gift Cards, with the first $50 winner to be randomly chosen this Friday! ACFAS is making the switch from a Group to a Page to better keep you informed of what’s happening at ACFAS and in the world of foot and ankle surgery. The things shared on the new Page can be easily accessed and shared among those who have Liked the page, since posts show up in your Newsfeed—no more having to search for the latest posts or news!

Make the switch today and keep yourself in the conversation by visiting Facebook.com/AmericanCollegeofFootandAnkleSurgeons.

Foot and Ankle Surgery

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A recent retrospective study examined the radiographic outcome of a modified triple arthrodesis, including fusions of the subtalar, talonavicular and first tarsometatarsal joints, in 21 patients with stage III posterior tibial tendon dysfunction (PTTD). During the study, a panel of clinicians blindly reviewed pre- and postoperative weight-bearing radiographs. The talo-first metatarsal, talocalcaneal and talonavicular coverage angles were measured on anteroposterior views, while the talo-first metatarsal, talocalcaneal, calcaneal pitch, talar declination angles and medial cuneiform to floor distance were measured on lateral views. Clinicians also performed a statistical analysis in order to compare pre- and postoperative measurements, assess the degree of correction and determine interobserver reliability of the radiographic measurements.

Clinicians found that the use of modified triple arthrodesis corrected the deformity seen in rigid stage III PTTD in a reliable and reproducible manner. All of the measurements improved significantly following a modified triple arthrodesis and all of the 22 feet examined in the study were corrected to normal cuneiform to floor distance and talonavicular coverage angle. In addition, nearly 91 percent of feet were corrected to a normal lateral talo-first metatarsal angle.


Researchers in South Korea have performed a study that examined whether joint-sparing surgery can help improve ankle osteoarthritis with severe talar tilt caused by paralytic disorders. The study examined 12 ankles in 11 patients with varus ankle osteoarthritis resulting from paralytic disorders such as residual polio, cerebral palsy, and idiopathic paralysis, along with cavovarus deformity of the foot. Researchers performed preoperative and postoperative assessments using the American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot score and a visual analogue scale (VAS). The Ankle Osteoarthritis Scale (AOS) was also used during the postoperative assessment, which was performed after a median of three years.

Researchers found that mean AOFAS scores and mean talar tilt both improved following the surgery. Degree of osteoarthritis according to Takakura classification, meanwhile, improved in all ankles except for two after the surgery. Mean heel alignment was reduced following the operation. The study concluded that medial varus ankle osteoarthritis from paralytic cavovarus could be improved even in cases where there is severe talar tilt.


A recent retrospective study examined the outcomes and postoperative complications associated with the use of total ankle arthroplasty in treating advanced ankle arthritis. Researchers examined the demographics, clinical outcomes, and radiographic characteristics of 100 S.T.A.R. ankle prostheses that were implanted in 97 patients between March 2005 and May 2010.

Researchers found that the average American Orthopaedic Foot and Ankle Society (AOFAS) score increased from 36.85 before the operation to 75.99 after a mean follow-up period of 36 months after the operation. Eighty-seven percent of patients also reported improvements in their quality of life. However, complications were observed in 27 ankles following primary surgery, and 21 prostheses required revision surgery. The number of prostheses that needed revision surgery included four patients who required arthrodesis. Complications were more likely to be observed in patients with a body mass index of 30 or more, though overall complication rates were similar to those observed with ankle fusion.

Practice Management

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Healthcare experts say that a direct mail effort as part of a comprehensive marketing plan can be more effective than email marketing. A 2012 study by the Direct Marketing Association found that direct mail had a 4.4 percent response rate, while that for email was only 0.12 percent; a Harvard 23 percent for email. While email is cheaper and more cost effective, a recipient is more likely to look at direct mail before deciding what to do with it.

To maximize marketing effectiveness, a practice should determine its audience and market accordingly, and direct special attention to marketing to existing patients. Direct mail usage should be limited to special promotions or solicitations, and used as a branding strategy or a call to action. The mail should look professional and engaging, and the message should be time-sensitive, reflect the practice's value, and be clearly linked to the practice's goals.

It must be remembered that medical advertising is regulated by the Federal Trade Commission and the local medical board. To target the mailing, a list should be compiled from demographics research and existing patient files, and potential rewards should be weighed against the cost of printing, which can range from $600 to $10,000 depending on the distribution size. Some metric, such as a unique Web address or phone number, should be used to measure the campaign's effectiveness.


Practices must be prepared after a physician retires or departs unexpectedly, at the risk of overburdening other physicians, upsetting patient flow, and potentially losing profits and patients. Preparations include determining who will assume a departing physician's patients in the short and long term, how much notice should be given, how the physician's payout and outstanding accounts receivables will be managed, how to resolve noncompete clauses and other legal issues, and how to recruit replacements.

Plans should be created when new physicians are hired, or when they are made partners or shareholders. If the physician leaving is a partner, include a clause in the buy-sell agreement stipulating that notice given for each month short of 12 months reduces the buyout by one-twelfth. A standing recruitment plan ensures that a practice will not be caught flat-footed when the time comes to hire a replacement. A lawyer should determine state and local rules on noncompete clauses, if the physician leaving owes anything for equipment or leases, and if the practice owes the departing physician anything. Liability tail coverage must also be considered. Patient information belongs to all parties, and not to any particular physician; a departing physician's access to patient records can be negotiated.


Medical practices often must decide whether to lease or buy their equipment, but the answer differs in each circumstance. Many banks offer low interest rates to physicians for capital purchases, which are preferable to the high rates and fees of equipment lease contracts. Further, most medical equipment purchases can utilize an accelerated depreciation schedule for a tax advantage up to $500 for the year the equipment was purchased and placed in service. However, if the equipment is likely to shortly wear out or become obsolete, a lease contract allows more flexibility to upgrade or replace.

To calculate return on investment, start with gross revenues collected. Subtract financing costs and operating costs, both indirect. This returns the net profit or loss. It is preferable to be cautious when estimating gross revenue, as it is better to be surprised with a surplus than with a deficit. The subtracted costs must be calculated carefully, remembering disposables, maintenance, technical support, allocated receptionist time, and billing staff time, among others. Before leasing or purchasing, ensure there is enough demand to create enough revenue so that there is a profit. Perform research and due diligence before making any decision.

Health Policy and Reimbursement

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The Obama administration's decision to delay the Affordable Care Act's employer mandate has prompted some to raise questions about its ability to implement other aspects of the healthcare reform law, including the government-run health insurance exchanges that are scheduled to be up and running on Oct. 1. Launching the exchanges is perhaps the biggest logistical and technological challenge associated with implementing the Affordable Care Act, since the sites must tie into systems operated by insurance companies and various federal agencies. Testing is underway on the government's computer systems, though experts say that there is no way to tell whether those systems will work before Oct. 1. The Obama administration says that the exchanges will open on time.


The Centers for Medicare and Medicaid Services (CMS) has released a proposed rule for Medicare payments to hospital outpatient departments (HOPDs). Under the proposed rule, which will affect the more than 4,000 hospitals that are paid under the outpatient prospective payment system, HOPDs will receive a 1.8 percent increase in Medicare reimbursements for calendar year 2014. CMS arrived at the 1.8 percent figure by taking the projected 2.5 percent hospital market basket increase from CMS' inpatient hospital proposed rule and subtracting 0.7 percent for productivity and outpatient adjustments.

CMS' proposed rule also groups payments for a variety of items and services--including biologicals and radiopharmaceuticals that serve as supplies when they are used in diagnostic tests or procedures, as well as biologicals that function as supplies or devices when used in surgeries--into one single payment. The agency says that bundling several different payments for these items and services into one payment will help encourage hospitals to provide services as efficiently as possible.

CMS is accepting comments from the public regarding its proposed rule until Sept. 6. The final version of the rule is scheduled to be published Nov. 1.


Frustrations over the paperwork burdens placed on hospitals and physicians by private recovery audit contractors working for the federal government have caught the attention of federal lawmakers. Members of the Senate Finance Committee are recommending changes to the Medicare RAC program, which has uncovered $1.4 billion in improper payments during the current fiscal year beginning Oct. 1, 2012, and returned $4.8 billion in incorrect pay since 2010. Hospitals and physicians complain that they are being forced to shift more time and resources away from patients and toward RAC demands.

Medicine, Drugs and Devices

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Researchers in Scotland have performed a study that examined the effects of using selective laser sintered (SLS) and fused deposition modelling (FDM) functionally optimized foot orthoses in patients with early-stage rheumatoid arthritis (RA). Fifteen patients who had RA for two years or less were given either SLS or FDM foot orthoses, while a third group of patients was given a standard device (SFO). Researchers compared the foot and ankle biomechanical effects of using these various types of foot orthoses and also monitored patients for adverse reactions, orthotic fit and comfort, and short-term symptom benefits.

The study found that the SLS and FDM foot orthoses provided a patient experience that was the same or better than that provided by SFO. Researchers found that both FDM and SLS significantly reduced peak rearfoot motion in comparison to shod, while the SLS orthosis significantly reduced peak pressures in the medial and lateral forefoot regions of interest. However, the average ankle internal moment decreased significantly in patients treated with the SFO orthosis and approached significance in the SLS orthosis.

The study concluded that functional optimization is a feasible approach for orthoses prescription in patients with early-stage RA, and that it has the potential to provide better mode-of-action responses for biomechanical therapeutic targets compared to standard devices.


Experts say that there is no one solution to the problem of medication non-adherence, a problem which a recent report from the National Community Pharmacists Association (NCPA) said costs the nation $290 billion in additional healthcare costs each year. However, Dr. Edmund Pazella of the health insurance company Aetna says that his company has found that there are a number of steps that can be taken in tandem to improve medication non-adherence, including giving drugs away for free and encouraging pharmacists to provide counseling for patients. Dr. Pazella noted that pharmacists can provide patients with important information about the purpose of their medications and how to take them, thus making it less likely that they will stop taking their prescriptions. NCPA's report agrees, saying that greater interaction between pharmacists and their patients can help address the problem of medication non-adherence.