News From ACFAS

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The due date for applications is one month from today! To earn support for your research with the 2012 ACFAS Clinical and Scientific Research Grant, you must apply by September 1, 2012. Fellows and Associate Members can receive up to $20,000 for research in podiatric foot and ankle surgery that will be of interest to members of the College.

The ACFAS Research Committee is encouraging the use of a scoring scale, including the ACFAS Scoring Scale, which has been fully validated by a volunteer ACFAS task force. Find the Scoring Scale, its Validation, the application and more information at acfas.org/grant. Your ACFAS member login is required. With the high number of websites out there that help you advertise your open career opportunities, sometimes the answer to where to turn for the best ROI can be hard to find. PodiatryCareers.org is the official online career center of the American College of Foot and Ankle Surgeons (ACFAS), and gives you access to the most qualified candidates: ACFAS Members. Affordable pricing packages are available depending upon your hiring needs. Post your jobs today!

Call (888) 884-8242 or visit the career page for more information and ACFAS member discounts on job posts. The ACFAS Fellowship Committee recently met and reviewed another Foot and Ankle Surgical Fellowship Program:

Family Foot and Ankle Specialists Fellowship
Greenville, TX
Fellowship Director: Steven P. Brancheau, DPM, FACFAS
Visit the ACFAS website to learn more!

This Fellowship exceeded the minimal ACFAS requirements for recognition, but has not yet had a Fellow matriculate through the program. Thus the Fellowship Committee has agreed to grant this program “Conditional Status” for its first year. Once the first year is complete, the program will be reconsidered for full “ACFAS Recognized Status."

ACFAS highly recommends the continuation of foot and ankle surgical education after residency in the form of a specialized fellowship. Programs meeting minimal requirements are officially recognized by the College, which will in turn provide support for these programs. For a complete listing of programs, support by ACFAS and minimal requirements, please visit our Fellowship Initiative page.

Foot and Ankle Surgery

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Magnetic resonance imaging (MRI) is helpful in the identification of specific bone lesions in the feet of diabetic patients, according to a study of radiographic and MRI foot analysis of 90 feet in 85 diabetic patients to evaluate prevalence of bone marrow changes. Seventeen feet exhibited vascular changes, and of this number 11 presented with infarct and six with necrosis. Researchers also determined that 20 feet had traumatic changes and half of these had edema that was visible on MRI. The researchers observed in five patients occult fractures with a visible fracture line via MRI, while an additional five patients exhibited visible fractures on both MRI and x-ray. Bone destruction was identified in eight feet, with bony debris visible on x-rays in three feet. Also, 11 patients exhibited bone dislocation and displacement, with the navicular bone dislocated most often. Twenty-four feet presented with osteochondral lesions, with the talus the most frequent area of occurrence, and 10 feet presented with osteomyelitis. The study was published in the European Journal of Radiology.


To determine if patients suffering from pain related to foot and ankle implants might benefit from extraction of those implants, a study of 69 patients undergoing elective removal of symptomatic implants was held to assess their pain experience. Patients said they experienced substantially less pain post-removal, with the average rating of pain on the visual analog scale falling from 3.06 to 0.88 and the average rating of present pain intensity slipping from 2.03 to 0.58. At six weeks following removal, 65 percent of patients disclosed no pain on either measure. A correspondence was drawn between preoperative and postoperative pain, and the two pain measures did not exhibit a significant difference on the basis of implant location or patient age or gender on account of the small sample size. Ninety-four percent of patients said they would repeat the procedure under the same conditions, while 91 percent reported satisfaction with the outcome.


A longitudinal study was held utilizing Z-shortening of ruptured Achilles tendons in nine patients that healed in continuity but were elongated. Surgery was administered to the patients, and all received prospective follow-up for two to five years, with final review performed at 32 ± 14 months post-surgery. All patients were capable of walking on tiptoes, and no participant used a heel lift or walked with a noticeable limp. Clinically deep-vein thrombosis did not develop in any patient, nor did any participants suffer a rerupture. Two patients underwent conservative management following a superficial surgical wound infection. Maximum calf circumference remained significantly decreased in the operated leg at final review, while the operated limb was substantially weaker than the nonoperated one.

Practice Management

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Many physicians do not get what they want from office staff, leading them to work harder for less money and lower job satisfaction. However, physicians can follow five steps nearly guaranteed to ease these situations. First, physicians must decide what they want. This may be more difficult than it sounds, as it involves articulating their desires without external stimuli. Yet without a definition, they cannot influence or control their circumstances. After their wants have been determined, the second thing to do is prioritize them. Sometimes desires will come into conflict, and in those occasions, priorities must be made. For example, if a phone is ringing and the physician is calling for a chaperone, but the medical assistant (MA) would leave the desk unattended by coming into an exam room, what should the MA do? This depends on the physician and the practice's specific preference.

The third step to take is to then communicate both the expectations and priorities to the practice's staff. A physician or manager's desires may not be intuitive or obvious to the staff, so these should be clearly conveyed. This may be done by writing them down, giving a brief statement and asking staff to paraphrase, not repeat, the messages to make sure they are understood. The fourth step is to hold staff accountable once the needs and priorities are communicated and understood. Doing so can provide an opportunity for clarifying and teaching, otherwise performance issues are likely to persist. An employee may be seriously flawed, but he or she could also be applying a different algorithm to a fact set. The two situations can be appropriately distinguished with clear expectations and counseling.

The fifth and final step is to encourage staff to ask for guidance when the physician's instructions appear to conflict with the previously determined objectives. Staff tend to immediately comply with a physician's instructions, no matter what. However, this can cause them to be chastised later for violating earlier instructions, and thus lead them to believe that previously set rules are arbitrary and cause them to depend constantly on the physician for instruction. Staff experiences may give them knowledge that the physician lacks, which could alter the physician's instructions if he or she hears the additional information.


The Medical Economics EHR Best Practices study found that quality hardware, outside help and buy-in from practice staff members are three key factors involved in easing the implementation of an electronic health record (EHR) system. Thirty of the primary care physicians participating in this study were asked to identify key factors for preparing implementation. Among the varied responses, many physicians said to hire a "scribe" for data gathering and creating templates, and to have one main resource person with the technology vendor to serve as a guide in the implementation process. The hardware should be quality, and not purchased in an attempt to cut corners. Practices should also get buy-in from the staff before implementation, and should set up a timeline for the completion of online training each week.

Weekly telephone conference calls with the vendor's implementation manager can help with the progress, troubleshooting problems and answering questions. In the survey, more than 60 percent of respondents reported negative impacts on patient flow during implementation. Unexpected costs now average $3,094 among study participants, but 85 percent of them said that no out-of-pocket charges were billed by vendors. Training was considered crucial for implementation success, but respondents were split regarding how adequately their staffs were trained for the EHR implementation. Despite some setbacks and negative views, most survey participants report progress in the EHR implementation.

Health Policy and Reimbursement

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Massachusetts has overturned a 2008 state prohibition on industry-provided meals for health professionals. Restaurateurs, drug companies, and medical device manufacturers had campaigned for the repeal, which was included in the state's $32.5 billion 2013 budget enacted in July. The repeal permits medical industry companies to cover the cost of "modest meals and refreshments" for health professionals in connection with educational presentations that are not certified by the Accreditation Council for Continuing Medical Education, with the new law stipulating that these presentations must happen "in a venue and manner conducive to informational communication."


A contractor working for the Centers for Medicare & Medicaid Services (CMS) has begun auditing Medicare providers that have received federal electronic health-record (EHR) system incentive payments. The CMS hired Figliozzi & Company of Garden City, N.Y., to perform the audits of providers that have attested to having achieved meaningful use of an EHR under the programs created by the American Recovery and Reinvestment Act of 2009.

According to the CMS' website, those being audited will receive a letter from Figliozzi & Company with the CMS logo on the letterhead. Providers are advised to "save the supporting electronic or paper documentation that supports [their] attestation," including documentation that will back up their payment calculations.


The U.S. Department of Health and Human Services (HHS) and the U.S. Justice Department have partnered with about a half-dozen health insurers to help prevent fraud and abuse in healthcare billing. The initiative is designed to share information on specific schemes, billing codes and even geographical hotspots that have been used in fraudulent activity. The government hopes, for example, to be able to immediately detect when payments are billed for the same patient in two different cities on the same day. Trade group America's Health Insurance Plans is participating in the partnership with the Blue Cross and Blue Shield Association as well as health plans, including Humana, UnitedHealth Group and WellPoint. A total of 21 groups, representing federal, state and private payers, have signed on so far.

Medicine, Drugs and Devices

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Cloud computing experts say healthcare is about to take a cue from other industries in adopting cloud-based computing as a way to exchange information, reduce costs and conduct business faster. MarketsandMarkets, a full service market research company and consulting firm, projects that the value of the global healthcare cloud computing market will balloon from $1.8 billion in 2011 to $5.4 billion in 2017, with growth partly fueled by health system reform and payment changes.


The Food and Drug Administration (FDA) has received a citizens' petition signed by about 35 physicians and public health officials to mandate limits on prescription painkillers through revisions to labeling directions on when and how doctors should prescribe them, and this action appears to be part of a wider effort to flag the dangers presented by opioids, especially when they are used at high dosages or over prolonged periods. The drugs at issue fall into two categories: short-acting drugs that combine a narcotic with an over-the-counter painkiller, and long-acting drugs that use a pure narcotic. The petition asked the FDA to restrict the medications' approved use to "severe" pain in patients other than those with cancer, and also asked the agency to put labels on the drugs urging physicians to limit the dosages at which the drugs are prescribed to treat noncancer pain and the period of time over which they are used.


iRobot, as part of an effort to diversify its product line in preparation for looming defense cuts, has unveiled a new telemedicine robot, the RP-VITA, to be made in partnership with InTouch Health for the purpose of helping patients with health emergencies receive faster treatment from specialists, particularly at nighttime. RP-VITA is outfitted with cameras, microphones, 3D mapping sensors, a stethoscope and a video screen, and the device lets physicians visit remote patients virtually, engaging in dialogues and even taking real-time measurements. The robot uses a Wi-Fi broadband connection to transmit and receive video, audio and navigation instructions.