News From ACFAS

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The ACFAS Nominating Committee is looking for the finest members to serve on the College's Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to take an active role in leading the profession, you are encouraged to submit a nomination application by September 4, 2015.

Visit acfas.org/nominations for complete details on the recommended criteria for candidates and the nomination application. For additional information, contact Executive Director Chris Mahaffey via email or at (773) 693-9300. Questions regarding eligibility criteria should be directed to Nominating Committee Chair Thomas S. Roukis, DPM, PhD, FACFAS via email or (608) 775-9673.

The Nominating Committee will announce recommended candidates to the membership no later than October 15, 2015. Candidate information and ballots will be emailed to all voting members no later than November 29, 2015. Electronic voting ends on December 29, 2015. New officers and directors take office during the ACFAS 2016 Annual Scientific Conference, set for February 11–14, 2016 in Austin, Texas.
Prospective poster presenters, don’t miss your chance to showcase your research at ACFAS 2016, February 11–14 in Austin, Texas.

All poster abstracts must be submitted to ACFAS by September 1, 2015 to be eligible for review. Refer to our Poster Exhibit Guidelines for details.

Each year, our poster competition brings together the latest discoveries in foot and ankle surgery in a vivid display that attracts both high viewing traffic and high praise from attendees. See and be seen at ACFAS 2016 and get your research noticed!
Hit the ground running with your office staff after the Oct. 1 ICD-10 transition and attend ACFAS’ Interactive Surgical Coding Workshop set for October 16–17 in Las Vegas.

Team up with your office staff, faculty and fellow attendees to code actual cases in an interactive, fast-paced learning environment that will help you fill in any gaps in those first critical weeks following the ICD-10 transition. Also learn strategies for improving your coding accuracy so you can obtain entitled reimbursement and better work with new requirements for modifiers, durable medical equipment and more.

This new style of classroom education also includes 12 continuing education contact hours, a comprehensive reference guide, breakfast and lunch. Spots are filling quickly, so register your office staff and yourself now at acfas.org/practicemanagement.
The ACFAS Fellowship Committee recently determined the following fellowship meets the minimal requirements to be upgraded to Recognized Status with the College after its first successful year:

Southeast Permanente Foot & Ankle Trauma & Reconstruction Surgical Fellowship, Atlanta, Georgia
Program Director: Daniel Tucker, DPM, FACFAS
acfas.org/fellowshiptucker

The following fellowships have been granted Conditional Status with ACFAS since the programs are new and have not yet had a fellow matriculate through:

Foot and Ankle Reconstruction Programs:
Greater Phoenix Foot & Ankle Fellowship, Phoenix, Arizona
Program Director: Eugene L. DelaCruz, DPM, FACFAS
acfas.org/fellowshipdelacruz

Newport Advanced Foot & Ankle Surgery Fellowship, Newport Beach, California
Program Director: D. Jeffrey Haupt, DPM, FACFAS
acfas.org/fellowshiphaupt

The CORE Foot and Ankle Advanced Reconstruction Fellowship, Phoenix, Arizona
Program Director: Ryan T. Scott, DPM, FACFAS
acfas.org/fellowshipscott

Sports Medicine Program:
Encino Specialty Surgery Center Sports Medicine Fellowship, Encino, California
Program Director: Franklin L. Kase, DPM, FACFAS, FAAPSM
acfas.org/fellowshipkase

All Conditional Status programs are considered for "Recognized Status" with ACFAS after the first fellow completes the program.

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org/fellowshipinitiative to review a complete listing of programs and minimal requirements.

Foot and Ankle Surgery

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Posterior capsulotomy can correct residual clubfoot deformity, but it often results in ankle stiffness. A study was conducted to observe clinical ankle range of motion (ROM) immediately following posterior capsulotomy as well as during long-term follow-up. Twenty feet were chosen for the retrospective clinical and radiographic review. Following capsulotomy, a long-leg cast was placed and maintained for a mean of 26 days. At cast removal, parents were trained and instructed to immediately begin home physiotherapy. The mean dorsiflexion in the capsulotomy group was significantly increased compared with the immediate postoperative ROM (-6.5 to +9.7 degrees). No significant reduction in this gain was noted at latest follow-up. Radiographically, a significant improvement in the lateral anterior tibial-calcaneal angle was found. Researchers suggested that placing the feet in casts for a shorter duration of time and providing early physiotherapy helps maintain ROM after capsulotomy.


A failed total ankle replacement (TAR) can result in peri-implant osteolysis. A recent study hypothesized that this reaction is brought about partly by autoinflammatory responses mediated via damage-associated molecular patterns (DAMPs, danger signals) and pattern-recognizing danger signal receptors (PRRs). Researchers immunostained peri-implant tissue and control samples from 10 patients with AES implants for hypoxia inducible factor-1a (HIF-1a), activated caspase-3, high-mobility group box 1 (HMGB1), receptor for advanced glycation end product (RAGE) and toll-like receptors TLR2 and TLR4. These results were displayed on a 0 to 4 scale. The tests showed that peri-implant tissue around failed TAR implants had a relatively high mean HIF-1a score of 3, although this was similar to control samples. HMGB1 (a DAMP) was seen to be mobilized from nuclei to cellular cytoplasm, and the active caspase-3+ cells were increased. All PRRs were increased in revision samples. Researchers concluded that autoinflammatory responses in failed TAR implants could be brought about by increased expression of HMGB1 and other danger signals.


Ankle arthrodesis is a popular treatment for many ankle issues, but it can cause complications such as foot pain and joint arthritis that may result in other problems for patients. A study investigated the biomechanical effects of ankle arthrodesis on the entire foot and ankle. The biomechanical performances of a normal foot and a foot with ankle arthrodesis were compared at three gait instants, first-peak, mid-stance and second-peak. In the foot with ankle arthrodesis, the plantar pressure was increased compared with the normal foot. The talonavicular joint and joints of the first to third rays in the hind- and mid-foot bore the majority of the loading and sustained substantially increased loading after ankle arthrodesis. The contact force and pressure of the subtalar joint decreased after surgery. This indicated that arthritis at this joint was not necessarily because of ankle arthrodesis but because of a progression of pre-existing degenerative changes. The information on the inner foot provided in this study can serve as a baseline for the optimization of surgical protocols and interventions for rehabilitation.

Practice Management

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Physician liability can be daunting, especially in the case of patient addictions. A recent West Virginia Supreme Court decision confirmed a fear shared by many physicians: the court ruled that patients could sue their doctors if they became addicted when the doctor negligently prescribed pain medication. The ruling is problematic in that most of the patients involved in the case were already abusing controlled substances when they sought treatment. In this type of situation, physicians are wondering how they can protect themselves from malpractice suits when patients are so desperate for pain relief. The Centers for Disease Control and Prevention noted four steps: (1) use prescription drug monitoring programs to identify patients who might be misusing prescription drugs, (2) use methadone or buprenorphine or other effective substitute treatments for those patients who have substance abuse problems, (3) discuss with patients the risks and benefits of pain treatment options, including ones that do not involve prescription painkillers and (4) follow best practices by screening for substance abuse and mental health problems, by avoiding combinations of prescription painkillers and sedatives unless there is a specific medical indication and by prescribing the lowest effective dose and only the quantity needed. In addition, physicians should also be sure to build a solid relationship with the patient to improve communication, and physicians should document all aspects of the patient's visit thoroughly in the event of a malpractice suit.


Electronic health records (EHRs) have been around for the last 20 years or so, but some believe practices are behind the times in terms of how EHRs help in the delivery of healthcare. The Physicians Practice Technology Survey revealed that only 53 percent of 1,181 respondents had fully implemented an EHR system. Sixty eight percent said they did not see a return on investment in EHRs, and one of the top problems cited was the drop in productivity due to EHRs. Experts agree that there are three primary reasons why physicians struggle with EHRs. First, many practices provide inadequate training. This can lead to frustration and waste time as well as money. Training should be timely and repeatable, and focus on specific daily tasks. The second common problem is inadequate implementation. Providers often spend too much time documenting the patient encounter and fail to make use of time-saving features like shortcuts, templates and built-in coding. In some cases, customization is not possible, but the EHRs still must be correctly implemented or small issues such as incorrectly setting up the dictionary can negatively impact a practice. The final problem is inadequate tech support. Many practices had vendors present during the first week of implementation, and then they are essentially on their own. Solve this by communicating with the vendor on a regular basis, including appointing a liaison to develop a relationship with the vendor.


Hospital checklists are meant to save lives, but research suggests that these lists have done little to improve infection rates and stave off patient deaths. An analysis of more than 200,000 procedures at 101 hospitals in Ontario, Canada, found no significant reductions in complications after surgical checklists were introduced. These results prove consistent with others around the world, including a hospital in Michigan that underwent a similar study and came away with stagnant outcomes. A survey of staff at ten U.K. hospitals aimed to determine why these checklists seem to have no effect. Fifty one percent of respondents said the staff resisted or failed to complete the checklist; 34 percent claimed the checklist was inappropriate or illogical; 29 percent agreed it was a waste of time. Further studies show that when checklists are successful, it is typically because a staff completely got on board with the concept. In exemplary cases, leaders who take the time to explain how to use the checklist usually end up getting results. Experts also recommend that hospitals modify standard checklists to help fit into the local workflow and produce a feeling of investment and ownership.

Health Policy and Reimbursement

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Healthcare spending will accelerate at a higher rate than the nation's overall economic growth over the next decade, the government forecast on July 28. The combination of expanded coverage under the Affordable Care Act, the aging population and rising demand will make it difficult for taxpayers, businesses and individual Americans to pay. By 2019, healthcare spending will increase at around six percent per year, compared with an annual average rise of four percent from 2008 through 2013. The Office of the Actuary in the Health and Human Services Department described the increase as "relatively modest" and notes that the forecast through 2024 does not foresee a return to the inflation rates prior to the 2008 recession. Healthcare as a share of the nation's overall economy is projected to grow from 17.4 percent in 2013 to 19.6 percent in 2024, the report says, accounting for nearly $1 of every $5 spent. Spending on Medicaid has also jumped. The 2013 increase was 6.1 percent, and the program is projected to have grown by 12 percent in 2014.


As healthcare consumers gain more power and responsibility regarding the type and quality of healthcare they receive, the future of revenue cycle management as it relates to cost continues to evolve. Jason Fugleberg, RN, BSN, vice president of Patient Services/chief nursing officer at Millinocket Regional Hospital in Maine, recently provided an overview of how to address primary charge capture challenges to best maximize revenue. Fugleberg says the primary charge capture problem he faces is that everything is done manually at his hospital. They use a sticker system that often gets very confusing and leads to revenue loss. Fugleberg believes that what is needed is a real-time charge capture system based on charting. The problem is that charges are not being missed on purpose, it is just that many institutions do not have good documentation systems. Ultimately, solving this issue drives down costs and allows for quality to shine through. "It's about expanding service lines and figuring out which ones are revenue-producing," said Fugleberg. "It's a tough business to be in right now. It will stabilize."


The recent major breach at UCLA Health has many experts saying that encrypting internal data within electronic health records (EHRs) is an important next step in security. Mac McMillan, CEO of CynergisTek, gave a keynote address at the College of Healthcare Information Management Executives Lead Forum just days after the breach and noted that EHR encryption is critical. McMillan said that the industry needs to have a serious discussion about how EHRs are constructed so that patient records within the EHR remain safe from hackers. Encrypting, according to McMillan, does not stop the hackers so much as slow them down to the point where recognizing suspicious activity becomes easy. This means encrypting passwords, which many organizations do not do, as an extra layer of defense should the EHR be compromised. "Whenever you see your environment suddenly get better, you'd better check, because when hackers get in, as soon as they can break in, they fix something and install their own back door," McMillan said. "I would say that we really have to do three things: we have to do behavioral monitoring, we have to move toward higher levels of encryption, and we have to act proactively and strategically going forward."

Medicine, Drugs and Devices

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Early mobilization postsurgery reduces the chances of multiple complications. Wearable sensors can track these movements and transmit the data wirelessly, which can aid recovery and motivate patients to engage in their own rehabilitation. A study assessed the ability of off-the-shelf activity sensors to remotely monitor patient postoperative mobility. Researchers generated 148 motion data points and found that the sensor's accuracy was high when placed over the ankles. Step length was found to be an independent predictor of sensor accuracy. Accuracy was also affected by several specific measures of a patient’s level of physical assistance. The researchers gathered the data and found that activity sensors are able to provide critical information about a patient's mobility status, although debilitated patients have a systematic underestimation bias.


Mobile health technology is now a major aspect of medical care in the U.S. Last year, the digital health market increased 62 percent and mobile apps and wearable devices are now mainstream. One poll indicates that six out of ten adults track their diet, weight and exercise. This is important to physicians, researchers and drug development teams because these devices produce copious amounts of data that can be used to create better patient care and more efficient drug development. The data available via mobile devices can potentially be useful for the healthcare industry whether it is in patient care and communication, disease management or public health reporting. "Finally, we can learn about a person beyond their clinical visit–which is only a small slice of their 'health pie,'" said Ida Sim, professor of medicine at University of California, San Francisco. "By getting multiple health snapshots, doctors will be able to provide patients with better medical support and preventative strategies that support overall physical and mental well-being."


The increase of non-clinical demands in today's busy age of healthcare means that doctors often have less time than before to actually see patients. This becomes a problem when hospitals must reach goals in certain areas of patient care to avoid being penalized. This is especially true with readmissions, where mistakes can lead to penalties from the Centers for Medicare and Medicaid Services as well as higher costs for unnecessary transfers. Physicians can turn to telehealth to assist in patient management. Telemedicine solutions help make collaboration and care coordination easier by allowing doctors, nurses and other hospital staff to quickly communicate patient records and other information via a mobile device. This can save time, resources and thousands of dollars. Transfers can cost a lot of money and a needless transfer is a burden on any practice. Telemedicine can help here as well; doctors can use mobile devices and other technologies to reach specialists quickly and determine whether or not a transfer is absolutely essential. Telehealth is being adopted across the country, and it offers hope that there is a modern way to combat existing inefficiencies and avoid penalties.