August 21, 2013
Have you seen the all-new yet?

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News From ACFAS

Two Surgical Skills Course Dates and Locations Still Open
Take advantage of two hands-on ACFAS Surgical Skills Courses: the Total Ankle Arthroplasty Surgical Skills Course, October 3-5 in Henderson, Nevada; or the Comprehensive Flatfoot Surgical Skills Course (Reconstruction and Arthrodesis), November 1-2 in Denver, Colorado. These skills courses are taught by a faculty of foot and ankle surgeons who specialize in these distinct areas and are ready to share their tips and lessons-learned with course participants on how to evaluate specific cases and refine their surgical philosophy based on what they see, hear and discuss. Earn up to 16 continuing education contact hours at either of these courses.

All other surgical skills courses have already sold out, so be sure to act fast if you’re interested in participating, as enrollment is limited. Download the entire skills course catalog to view more details about these courses. You may apply to register for the Total Ankle Arthroplasty course by filling out the Application Form and faxing it to ACFAS Headquarters at (800) 382-8270.
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August Podcasts Feature Discussion, Debate and Discernment
Listen to the intellect brought forth by your surgical peers in the two newest ACFAS podcasts released this month: Arthroeresis – Pros and Cons released August 1, and How to Find a Job just released August 15. Hear surgical opinions on anything from knowing how to preventatively intervene using an arthroeresis for pediatric flatfoot versus when not to, to hearing valuable tips and insights from some of the College’s seasoned members on how to find a job while navigating all the bumps in the road leading to signing your employment contract.

Download these podcasts by visiting and click “Podcasts.”
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Applications Now Being Accepted for Board Nominations
The ACFAS Nominating Committee is looking for the finest, most fitting 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 15, 2013.

Visit for complete details on the recommended criteria for candidates and the nomination application. You may also email Executive Director Chris Mahaffey, or call him at (773) 693-9300. Questions regarding eligibility criteria should be directed to Nominating Committee Chair Michelle L. Butterworth, DPM, FACFAS (email), or call her at (843) 355-9690.

The Nominating Committee will announce recommended candidates to the membership no later than October 31, 2013. Candidate information and ballots will be e-mailed to all voting members no later than December 15, 2013. Electronic voting will end on January 14, 2014. New officers and directors will take office during the ACFAS 2014 Annual Scientific Conference set for February 27-March 2, 2014 in Orlando, Florida.
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Find the Right Job for You at
Visit today and register as a job seeker to further your career in foot and ankle surgery – your passion!, an ACFAS benefits partner, offers a career center designed specifically to fuel this passion with its library full of distinguished career opportunities in this field. is the online site to explore job openings posted by some of the finest groups, hospitals and practices in the business! With the ability to search job openings by category, location, employer, date posted and career level, the opportunities are endless. also offers pertinent resources to help further your career, including newsletters and articles about healthcare trends and issues, recruitment tips and tools, and even more exclusive content. The benefits of only increase once you register and post your resume so job seekers are able to find you. It also gives you the ability to sign-up for job alerts, which notify you when a job related to your specific interests is posted.

You’ve already decided this is the career path you will devote your talents to; now it’s time to find a position that fuels that dedication and allows you to be successful in your career.
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Foot and Ankle Surgery

Comparison of the Short-Term and Long-Term Results of the Ponseti Method in the Treatment of Idiopathic Pes Equinovarus
A recent study examined the short- and long-term outcomes of using the Ponseti method in treating congenital club foot. The study examined 195 consecutive infants (303 feet) with idiopathic club foot, all of whom were treated with the Ponseti method from 2005 to 2012. The use of the Ponseti method brought about primary correction in all of the children. Surgical correction of relapses was performed in 30 percent of the infants according to the Ponseti method (re-tenotomy of the Achilles tendon and transposition of the tibialis anterior) and in 70 percent of the infants by alternative techniques. Researchers discovered that the number of relapses indicated by surgery increased as the follow-up period increased. Relapses occurred in 72 percent of the patients who started treatment in 2005, though only 3 percent of patients who were treated in 2011 experienced recurrences. Researchers concluded that it is impossible to cure all cases of congenital club foot using only casting, tenotomy of the Achilles tendon, and transposition of the tibialis anterior.

From the article of the same title
International Orthopaedics (08/07/13) Ostadal, M.; Chomiak, J.; Dungl, P.; et al.
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Comparison of Open Lateral Release and Transarticular Lateral Release in Distal Chevron Metatarsal Osteotomy for Hallux Valgus Correction
A study by researchers in South Korea has found that patients who undergo distal chevron metatarsal osteotomy (DCMO) to treat hallux valgus (HV) experience essentially the same clinical and radiographic outcomes regardless of whether open lateral soft tissue release (OLSTR) or transarticular lateral soft tissue release (TLSTR) is used. Researchers came to that conclusion after examining weight-bearing anteroposterior radiographs of 138 patients (185 feet) with HV who underwent DCMO and Akin phalangeal osteotomy. Eighty-four of the feet were treated with OLSTR, while the remainder were treated with TLSTR. The only significant differences that were observed between the two groups were postoperative complications such as first metatarsophalangeal joint (MTPJ) stiffness in the OLSTR group and postoperative hallux varus in the TLSTR group. While both OLSTR and TLSTR brought about essentially the same outcomes, researchers noted that different precautions should be taken into consideration when selecting the type of lateral soft tissue release that will be used. This is because each technique is associated with different potential complications, researchers said.

From the article of the same title
International Orthopaedics (08/06/13) Ahn, J.Y.; Lee, H.S. ; Chun, H.; et al.
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Outcome of Limited Forefoot Amputation with Primary Closure in Patients with Diabetes
Primary wound closure following limited amputation of the foot in diabetics is both safe and effective when performed in conjunction with the appropriate use of antibiotics, a recent study has found. The study involved 74 consecutive diabetic patients with osteomyelitis, an unhealed ulcer and blood pressure in the toe that was higher than 45 mmHg. All of the study's participants underwent limited amputation of the foot with primary wound closure. The study found that all of the wounds healed primarily at a median of 37 days, and that 23 patients experienced further ulceration at a median of six months. Twelve of those 23 patients needed further amputation.

From the article of the same title
Bone & Joint Journal (08/13) Vol. 95-B, No. 8, P. 1083 Shaikh, N.; Vaughn, P.; Varty, K.; et al.
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Practice Management

Toxic Docs Require Management Finesse
Disruptive physician behavior, which can include verbal abuse or physical or sexual harassment, is a common problem at doctors' practices and hospitals. According to a study performed by the American College of Physician Executives two years ago, more than two thirds of doctors said they observed physicians engaging in disruptive behavior such as disrupting patient care or collegial relationships at least once a month. In order to determine how to handle such behavior, doctors' practices and hospitals need to be sure to examine what is driving the disruptive actions and develop programs that can help problem doctors learn how to behave better, said Dr. Hardley Paolini, a psychologist and the director of Physician Support Services at Florida Hospital in Orlando. Other experts say that hospitals and physician groups should be sure to deal with disruptive behavior when it first appears, as well as when it recurs. Hospitals and physician groups should also not make excuses for doctors who behave badly and are seen as being high performers, and should instead hold peer reviews for problem doctors and discipline them when necessary. Finally, experts say that hospitals and doctors' practices should be sure to strike an appropriate balance between the need to manage disruptive behavior and the need to care for the victims of such behavior. That means not "railroading" the troublesome doctor, as well as doing what is best for the organization and everyone involved.

From the article of the same title
HealthLeaders Media (08/08/13) Cantlupe, Joe
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EHR Transition Causes Its Own Headaches
Healthcare industry observers say that a lawsuit currently underway in Wisconsin should serve as a cautionary tale for doctors' practices that are considering dumping their existing electronic health records (EHR) systems for new ones. The lawsuit involves the community health center Milwaukee Health Services, which decided to stop using an EHR system that was allegedly not functioning the way the vendor, Business Computer Applications, promised it would. Business Computer Applications subsequently locked Milwaukee Health Services out of its on-site backup servers, thereby preventing it from accessing its patients data, due to the clinic's alleged failure to pay it more than $280,000 in back service charges. The vendor has said that it will not release the records until the bill is paid. Milwaukee Health Services' legal battle to get Business Computer Applications to release the records highlights the need for doctors' practices to ensure that contracts with EHR vendors have terms for contract termination that are favorable to them. Perhaps the most important thing that needs to be spelled out in such contracts is how practices will be able to access patient data in the event the contract with the EHR is terminated. Practices also need to know how much it will cost to convert data following a contract termination, as well as how much time it will take to convert the data. Finally, vendors should be contractually required to cooperate with new vendors in the event their services are no longer needed.

From the article of the same title
American Medical News (08/05/13) Dolan, Pamela Lewis
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Health Policy and Reimbursement

New York Health Plan Settles HIPAA Charges Stemming From Data on Leased Copiers
The health insurance company Affinity Health Plan has settled claims that its alleged violations of the Health Insurance Portability and Accountability Act's (HIPAA) Security Rule resulted in the disclosure of hundreds of thousands of patients' data in 2010. The $1.2 million settlement will put a rest to allegations that Affinity Health Plan failed to erase electronic protected health information (ePHI) from photocopiers before it returned them to leasing agents. The Department of Health and Human Services' Office of Civil Rights (OCR) found that this failure resulted in the disclosure of the ePHI of 344,579 people. OCR's investigation also found that Affinity did not assess and identify possible security risks and vulnerabilities associated with capturing and storing ePHI on copier hard drives. In addition, the insurance company was faulted with failing to implement policies governing the disposal of ePHI that was stored on copier hard drives. OCR Director Leon Rodriguez said the settlement--which also requires Affinity Health plan to retrieve ePHI from previously leased copiers and to take steps to protect such information--underscores the need for HIPAA-covered organizations to erase any personal information from hard drives before the devices are sent back to leasing agents, thrown away, or recycled.

From the article of the same title
BNA Snapshot (08/19/2013) Plank, Kendra Casey
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A Limit on Consumer Costs is Delayed in Healthcare Law
The Obama administration has announced that it is delaying the implementation of the Affordable Care Act's limits on out-of-pocket healthcare expenses by one year, until 2015. The law had required health insurance plans to adopt a $6,350 limit on out-of-pocket expenses for individuals and a $12,700 limit on such expenses for families beginning next year. But the Obama administration decided to delay the implementation of the requirement because many employers and health insurance companies said that they needed more time to upgrade their computer systems so that they could comply. The decision to delay the requirement means that some insurers will be allowed to set no limits on out-of-pocket expenses or limits that are higher than those called for by the Affordable Care Act next year.

From the article of the same title
New York Times (08/13/13) Pear, Robert
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Docs Lobby to Keep Stark Exemptions
Congress is considering legislation that would eliminate the Stark Law's exemptions for in-office ancillary services, much to the consternation of more than 30 national medical groups who oppose such a move. Under the Stark Law, doctors are forbidden from making self-referrals for certain services, with the exception of services such as diagnostic imaging and radiation therapy. The American Medical Association and the American College of Surgeons, among other medical groups, say that the exemptions are beneficial because they encourage care coordination. The groups also note that eliminating the exemptions would have a number of ramifications, including forcing Medicare patients to obtain care from more expensive facilities, which in turn would raise their out-of-pocket costs as well as the costs for the Medicare program. Others say that removing the exemptions would make it difficult for independent doctors to remain competitive.

From the article of the same title
MedPage Today (08/13/13) Pittman, David
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Low Risk Ankle Rule Reduces Pediatric Ankle X-Rays
A study published in the Canadian Medical Association Journal has found that the use of the Low Risk Ankle Rule on children who are taken to emergency rooms for ankle injuries significantly reduces the number of unneeded radiographs without missing fractures and without increased patient or clinician dissatisfaction. The study examined 2,151 patients between the ages of three and 16 at three intervention sites where the rule was used and three control sites. The study consisted of three phases, the first of which included normal emergency room visits without the use of the Low Risk Ankle Rule, which consists of physical education, reminders, and a computerized decision support system. Researchers began using the Low Risk Ankle Rule at intervention sites during the second phase of the study but used only the decision support system during the third phase. No interventions were used at the control sites. Researchers found that 96.5 percent of patients at the intervention sites and 90.2 percent of those at the control sites underwent radiography during the first phase, and that the frequency of radiography at intervention sites decreased by 21.9 percent compared to the frequency observed at control sites during phase two. This decrease continued through the third phase. Researchers concluded that their findings were consistent with those of other studies that examined the use of clinical prediction rules in emergency rooms.

From the article of the same title
Diagnostic Imaging (08/12/13)
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9 ACOs Dump Medicare’s Pioneer Program
Nine organizations have announced that they are leaving Medicare's Pioneer Accountable Care Organization (ACO) program, which aims to realign payment incentives while simultaneously working to improve care for Medicare beneficiaries. Seven of those organizations have announced plans to transition to the Medicare Shared Savings Program, a less financially-stringent ACO model that allows bonus-only financial arrangements. The remaining two organizations said that they lost $4 million during their participation of the Pioneer ACO program. The Centers for Medicare & Medicaid Services also reported that all of the Pioneer ACOs exceeded industry benchmarks during their first year but that only 13 saved enough money to share the funds with CMS. CMS said that it was satisfied with those results.

From the article of the same title
Medical Economics (08/10/13) Verdon, Daniel R.
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Medicine, Drugs and Devices

New Use of Old Technology Could Aid Diabetic Foot Disease
A study published in the journal Diabetes Care has found that the use of Raman spectroscopy could allow doctors to diagnose osteomyelitis in the feet of diabetics earlier than what is possible using other methods. Researchers developed a portable bedside instrument using Ramon spectroscopy and utilized the device to examine bone specimens from 17 patients who had been diagnosed with osteomyelitis in their feet, 11 of whom needed amputations and six of whom were undergoing surgery to collect a bone biopsy specimen. Researchers observed the presence of brushite on these bone specimens and found that the presence of brushite was associated with infected areas of bone. They also noted that bacterial biofilm likely created the environment needed to form brushite, and that the presence of brushite was likely not the result of an immune or inflammatory response or excessive bone remodeling. The finding suggests that mineralization could be an important composition marker of the kind of early-stage bone infection that is typical of diabetic osteomyelitis. This in turn could allow for the better use of antibiotics and surgery in patients suffering from this condition, researchers said.

From the article of the same title
Medscape (08/12/13) Melville, Nancy A.
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Activity Classification in Users of Ankle Foot Orthoses
A study by researchers at the University of Virginia has found that ankle foot orthoses (AFOs) are a suitable sensor platform for future research in activity classification and gait monitoring in AFO users with perturbed gait using limited training data. The study examined eight patients who wore bilateral AFOs that were modified to include shank and foot mounted triaxial accelerometers and gyroscopes as well as hardware that caused free rotation of the ankle, plantarflexion or "equinus" gait and locked ankle joint. For each of the three gait problems that were simulated, participants performed eight gait activities at various slopes and while standing, sitting and lying. Researchers utilized a decision tree-nearest algorithm to classify activities using subject-specific training, and found that the algorithm had an overall mean sensitivity of 95 percent using half of the data (~ 140s) for training and as much as 90 percent sensitivity when using 25 percent of the data (~ 70s) for training. In addition, high sensitivities and PPV were achieved for all annotated gait patterns for all the gait problems, with the exception of stair climbing and descending. Non-annotated walking and standing were classified with less sensitivity than the corresponding annotated events.

From the article of the same title
Gait & Posture (07/13) Archer, C.M.; Lach, J.; Chen, S.; et al.
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