August 29, 2012

Double the Updates

Due to a publishing house misprint with the latest edition of ACFAS Update, you will be seeing double the issues of your member newsletter this month. As we work with the vendor to correct the issue, you can read the latest edition of ACFAS Update online at until a corrected print version is mailed to you.

We apologize for any inconvenience and appreciate your patience. We hope you enjoy your reading!
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News From ACFAS

Last Chance to Submit Board of Directors Nominations – Due Sept. 4
This is the final week to submit nominations for the ACFAS Board of Directors. Do you want to make an impact on the future of ACFAS? Nominate yourself or an exceptional colleague today, before it's too late! You have until Tuesday, September 4 to do so.

Again, nominations are now being accepted for two three-year director terms on the Board of Directors. ACFAS Fellows who meet criteria for election are encouraged to submit a nomination application to Executive Director Chris Mahaffey by an extended deadline of September 4. The Nominating Committee will announce recommended candidates to the membership no later than October 5. Candidate information and ballots will be e-mailed to all voting members no later than November 29. Electronic voting will end on December 29. New officers and directors will take office during the ACFAS 2013 Annual Scientific Conference set for February 11-14, 2013, in Las Vegas.

For complete details on the recommended criteria for candidates and the nomination application, visit, or contact Chris Mahaffey at 773-693-9300 or Questions regarding eligibility criteria should be directed to Nominating Committee Chair Glenn M. Weinraub, DPM, FACFAS, at 510-248-3039 or
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How Do You Benefit from Becoming an ACFAS Member?
We know you have a lot going on – new beginnings, taking the next steps in your professional life, and now, ACFAS is happy to help commemorate your many career firsts:
  • First year of residency?
    ACFAS congratulates you on achieving your DPM, and wants to help you celebrate by providing your first year of membership at no cost. Get all the benefits of the College, including the Journal of Foot & Ankle Surgery delivered to your mailbox, free for a year!
  • Passed Part 1 of the ABPS Certification Exam in July?
    After completing the written portion, you're on the road to Board Certification! Advertise your ABPS status, and take advantage of the many educational resources ACFAS offers, by joining the College as an Associate Member. Once you join, you can list the credential “AACFAS” after your name. And to help you make the transition from resident to practitioner, ACFAS is waiving the application processing fee and dues for the rest of 2012, as well as holding a raffle of all new Associate Member applicants (who passed the exam in 2012) that submit their applications by November 15, 2012. Your names will be put in a drawing to win an Apple iPad. The winner will be announced in an upcoming issue of ACFAS Update.
  • Passed Part 2 of the ABPS Certification Exam in July?
    Congratulations on your certification, and on completing this important milestone in your career! Become recognized as a Fellow Member of ACFAS, which will allow you to list the esteemed “FACFAS” credential after your name. Once you’ve received your exam results from ABPS, contact ACFAS to become part of the best: a Fellow Member of the American College of Foot and Ankle Surgeons. The sooner you apply, the more quickly you can enjoy all the benefits of membership.
For questions or an application, visit or contact
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Denver Advances in Forefoot Surgery

We look forward to the routines the school year brings. There is comfort in getting back into a regular routine. Remember to schedule an educational offering by ACFAS in your fall schedule.

Start fall off on the right foot by making time in your busy schedule to attend the Advances in Forefoot Surgery Workshop & Seminar, September 14-15, provided by ACFAS and Division 4.

The deadline to book your hotel is approaching, so be sure to make your arrangements today!
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Foot and Ankle Surgery

Interpositional Arthroplasty of the First Metatarsophalangeal Joint Using a Regenerative Tissue Matrix for the Treatment of Advanced Hallux Rigidus
Hallux rigidus refers to the painful osteoarthritis of the first metatarsophalangeal (MTP) joint, which can be difficult to treat in young and active patients who fail conservative treatment. The aim of this study is to report the five-year follow-up of a joint preservation technique for the treatment of advanced hallux rigidus. Preservation of the first MTP joint is performed using a human acellular dermal regenerative matrix as an interpositional arthroplasty graft. Of the first nine consecutive patients in the original study cohort, six patients were available for follow-up, with an average follow-up of 5.43 years. No patient had a subsequent fusion or additional procedure performed on their first MTP joint. Average preoperative modified AOFAS (American Orthopedic Foot and Ankle) scores was 38. Average postoperative AOFAS was 65.8, and all patients were satisfied with their results.

The researchers concluded that interpositional arthroplasty of the first MTP joint using a regenerative tissue matrix has led to reliable pain relief and preserved function at an average follow-up of 5.4 years in six patients. The authors recommend this technique to active patients with advanced hallux rigidus who want to delay a fusion of their first MTP joint.

From the article of the same title
Foot & Ankle Specialist (08/12) Vol. 05, No. 4
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Primary Outcomes of the Congenital Vertical Talus Correction Using the Dobbs Method of Serial Casting and Limited Surgery
A study was held to determine whether treatment of congenital vertical talus through the Dobbs method of serial manipulation, casting and limited surgery would yield favorable outcomes, even in older pediatric patients and syndromic cases. Fifteen feet of 10 patients aged one month to nine years were treated via manipulation and serial casting or the reverse Ponseti method, followed by percutaneous Achilles tenotomy and limited open reduction of the talonavicular joint. Clinical and radiological assessment of all patients was carried out in an average follow-up period of two years. All patients had plantigrade and flexible feet with positive radiographic correction at two years follow-up, while significant improvement in the mean talocalcaneal angle and the talar axis metatarsal base angle before and after treatment was observed. The mean talocalcaneal angle was 70.5 degrees ± 10.5 degrees prior to the procedure and 31 degrees ± 5.2 degrees after. The mean talar axis metatarsal base improved from 60 degrees ± 11.4 degrees before treatment to 15 degrees ± 6.7 degrees after treatment.

From the article of the same title
Journal of Children's Orthopaedics (08/01/12) Vol. 6, No. 4, P. 307 Aslani, Hossein; Sadigi, Ali; Tabrizi, Ali; et al.
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Is Early Operative Fixation of Unstable Ankle Fractures Cost Effective? Comparison of the Cost of Early Versus Late Surgery
A retrospective study was held of 98 patients who suffered an ankle fracture requiring early operative fixation, and the inpatient length of stay and the cost of surgery less than and more than 24 and 48 hours from admission was ascertained. Cost and length of stay were substantially different between patients who were operated on in less than and more than 24 hours from admission and those who underwent fixation in less than or more than 48 hours. No difference in cost and length of stay between the two groups operated on in less than 24 and 48 hours was observed. However, operations that were delayed by more than 48 hours did lead to significant increases in cost and length of stay.

From the article of the same title
European Journal of Orthopaedic Surgery and Traumatology (08/12) Manoukian, Dimitrios; Leivadiotou, Dimitra; Williams, William
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Tenodesis Reconstruction for Chronic Ankle Instability: Graft Considerations and Structures at Risk With Tunnel Placement
Non-anatomic surgical reconstructions of the lateral ankle ligament call for the use of autograft or allograft tendons to recreate the injured anterior talofibular ligament (ATFL) and the calcaneofibular ligament (CFL). In this study, researchers sought to determine the minimum, maximum and average graft length requirements for a modified Chrisman–Snook procedure. Modified Chrisman–Snook lateral ligament reconstructions were performed on 10 cadaveric below-the-knee specimens, with no known pathology. The structures at risk during drilling of the bone tunnels were documented to guide recommendations for tunnel placement. Transosseus tunnels were placed through-and-through the fibula, talus, and calcaneus at the origin and insertion sites of the ATFL and CFL.

The minimum, maximum, and average graft length requirements were approximately 91 mm, 170 mm, and 120.7 mm, respectively, while the average graft requirement was roughly 120 mm. The length of graft was correlated with the height of the patient. When performing the modified Chrisman–Snook, the length of the graft should measure approximately 120 mm, but considerable variability exists depending on the size of the patient. The transosseus tunnels should be made using either a blind hole technique or guide wire to avoid perforating the medial cortex to avoid injury to medial structures.

From the article of the same title
Foot & Ankle Specialist (07/12) Meacham, Benjamin P.; Granata, James; Berlet, Gregory
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Practice Management

Patient Portals "Critical" for Physicians' Practices
Patient portals are expected to become key tools at many physician practices because the deployment of patient portal-like technology will make it easier for physicians to comply with Stage 2 rules for the Medicare/Medicaid Electronic Health Record (EHR) Incentive Programs. One of the rules' core mandates is that more than half of all unique patients seen by the eligible provider (EP) during the EHR reporting period are supplied online access to their health information within four business days after the information is available to the EP, while over 10 percent of all unique patients seen by the EP, or their authorized representatives, must view, download or send their health information to a third party within four business days. Physician reluctance to adopt patient portal technology is an obstacle to implementation, but physicians' concern that they will be inundated with patient messages and queries is a "myth," according to Peter Kilbridge, a senior research director with the Advisory Board Company's Information Technology program suite.

From the article of the same title
Physicians Practice (08/23/12) Westgate, Aubrey
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"Informed Decision" May Irk Surgeons as it Cuts Costs, Improves Quality
The rate of unnecessary surgery could be significantly reduced and the quality of care improved by the practice of informed medical decisions, in which a primary care physician orders a patient to a class, a DVD or an interactive online tool, rather than to a specialist for a non-emergent procedure. Patients would instead learn from experts, perhaps hired by the health system or the payers, whether they meet criteria for the surgery or whether there are other workable options. Surgeons are removed from the decision-making process because of obvious conflicts of interest they may have, conscious or unconscious. "Surgeons don't always present things in an unbiased fashion," concedes Lisa Cannada with the American Academy of Orthopaedic Surgeons. "A surgeon with a specialty in a certain procedure believes a patient will benefit, and instead of trying physical therapy and injections, they'll just go right ahead and do the procedure." In June, the Center for Medicare & Medicaid Innovation allocated $26 million to the Dartmouth Institute to deploy shared-decision models throughout 15 million healthcare systems covering 50 million patients in 17 states, while the Informed Medical Decisions Foundation is creating tools for health plans and others to help patients learn more about the procedures they are about to receive.

From the article of the same title
HealthLeaders Media (08/16/12) Clark, Cheryl
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Effective Scheduling Tips for Your Medical Practice
To implement effective scheduling, a physician practice must know the lead times relative to different types of appointments so that the physician can correctly interpret the actual appointment time. Physicians also should adopt a realistic view of scheduling, and not arbitrarily schedule according to industry standards, but rather go by how long it takes a specific doctor to complete specific procedures and exams. Work-ins also should be planned, so that specific times for same-day appointments are protected. Also recommended is scheduling appointments at the average time required plus one standard deviation to predictably complete 66 percent of exams within the apportioned time, or the average time required plus two standard deviations to finish 95 percent of exams within the allotted period. Finally, physicians should strive to stay on time as much as possible.

From the article of the same title
Physicians Practice (08/22/12) Stryker, Carol
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Health Policy and Reimbursement

Final Stage 2 Rule Offers Delay, New Measures
The Centers for Medicare and Medicaid Services (CMS) have introduced a timeline delay, new core measures and an electronic reporting mandate as part of the meaningful use Stage 2 final rule. The most important of these changes for providers is likely the Stage 2 timeline delay that allows providers who first attested to Stage 1 criteria in 2011 to delay the onset of Stage 2 criteria until 2014. During 2014, providers beyond the first year of demonstrating meaningful use will have a three-month quarter reporting period to allow up to nine additional months to upgrade certified EHR technology to the edition for that year. The agency is also introducing a three-month EHR reporting period instead of a full year of reporting for providers attesting to either Stage 1 or Stage 2 in 2014. Additionally, the CMS final rule provides a flexible reporting period for 2014. Almost all of the Stage 1 core and menu objectives included in the proposed rule are being finalized for Stage 2, and the final rule adds outpatient lab reporting for hospitals and recording clinical notes as a menu objective for both eligible professionals and hospitals. There will be 20 measures for eligible practitioners and 19 for eligible hospitals. Two new objectives for the core measures are use of secure electronic messaging to communicate with patients and automatic tracking of medications. To make these processes easier, CMS finalized the ability to use a batch reporting process for meaningful use.

From the article of the same title
Health Imaging (08/23/12) Walsh, Beth
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One-Year Delay on ICD-10 to October 2014 Finalized
A 12-month delay in the compliance deadline for the nationwide switchover to ICD-10 code sets has been finalized by the federal government, with the deadline to be shifted to Oct. 1, 2014, so that healthcare organizations, especially small organizations, will have sufficient time to prepare for the conversion and conduct rigorous testing, according to the Department of Health and Human Services (HHS). The postponement was included by HHS in a final rule that sets a unique health plan identifier for all insurers, which will save the U.S. healthcare system approximately $6 billion over the next 10 years. "These new standards are a part of our efforts to help providers and health plans spend less time filling out paperwork and more time seeing their patients," says HHS Secretary Kathleen Sebelius.

From the article of the same title
Modern Healthcare (08/24/12) McKinney, Maureen
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AHRQ Extends Comment Period on Using IT To Measure Care Quality
The Agency for Healthcare Research and Quality's (AHRQ) public comment period for its request for information (RFI) on successful strategies for using IT to quantify healthcare quality has been extended until Sept. 21, as reported by Health Data Management. AHRQ's RFI features questions about issues that include whose voices are not being heard at the convergence of health IT and quality measurement; the infrastructure required to devise quality measures that would be of interest to consumers; ways to motivate developers to create new electronic quality measures; and the kinds of quality measures that could be supported by a mix of natural language processing and structured data. The College of Healthcare Information Management Executives sent a letter in response to the RFI, in which they stated that "although [electronic health record] products were able to automatically produce [clinical quality measure] reports, the data [were] inaccurate, inconsistent and largely incomparable across different providers." The letter urged AHRQ to establish a guide to help healthcare providers exploit IT tools to realize full, accurate and consistent disclosure of clinical quality measures.

From the article of the same title
iHealthBeat (08/23/12)
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U.S. Medicare Spending Forecast Reduced in New CBO Analysis
The Congressional Budget Office (CBO) has reduced its Medicare spending projections by $19 billion for this year and by $169 billion over the coming 10 years from earlier in 2012, and spending is forecast at $7.7 trillion for the decade ending in 2022. The revision reflects reduced spending growth for physicians, hospitals and prescription drugs since the U.S. economic recession. CBO also forecast a 7 percent decline in Medicaid spending over the coming decade, largely due to the Supreme Court's recent decision on President Barack Obama's healthcare reform law. CBO's lower spending numbers are not enough to delay a potential crisis for Medicare in 2024, when trustees expect the depletion of a government trust fund that helps cover hospital benefits.

From the article of the same title
Reuters (08/22/12) Morgan, David
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Survey: Medical Errors Continue to Worry Patients
A recent Wolters Kluwer Health Survey of 1,000 Americans finds that about three in 10 have experienced a medical mistake either firsthand or via a third-party. Seventy-three percent of respondents expressed worry about medical errors, with 45 percent saying they were "very" worried. Causes for error were attributed to doctors and nurses being hurried (26 percent), staff being tired (14 percent) and hospitals and practices experiencing staff shortages (12 percent). About 19 percent of respondents delayed getting a procedure for a day when the doctor may be more focused or rested, such as earlier in the week; 18 percent have asked a doctor or nurse to wash their hands; and 55 percent of adults between the ages of 35 and 54 have received an erroneous healthcare bill.

From "Medical Errors Continue to Dog Healthcare"
Healthcare IT News (08/17/12) Kearns, Madelyn
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Revised CPT Book Includes New Codes for Care Coordination
The American Medical Association (AMA) has updated the CPT 2013 Professional Edition with codes for care coordination that patients with complex, ongoing health issues receive within a patient-centered medical home, accountable care organization or other unique medical service delivery model. Those involved in the revision say the codes 99487-99489 were developed so that medical practices could bill for time that was not necessarily face-to-face but spent linking patients to community services, switching them from inpatient to other settings and preventing readmissions. The codes should be employed for claims filed as of Jan. 1, 2013. The revised book also includes substantial modifications to cardiology, neurologic testing and psychiatry codes, and the AMA undertook the update in response to technological advances entailing that some services have become much more common while others are no longer administered.

From the article of the same title
American Medical News (08/16/12) Elliott, Victoria Stagg
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Medicine, Drugs and Devices

Coming Next: Using an App as Prescribed
Smartphone apps may soon be used as medical devices prescribed by doctors and paid for by insurance to help patients with things like monitoring heart rates and managing diabetes. There is great potential to cut healthcare costs if the apps can reduce the amount of medical care that patients need, with the cost of diabetes treatment alone totaling $174 billion in 2007. There are issues to be worked out first, though, as a healthcare app cannot be launched with bugs that will be fixed later, as happens with most other apps. WellDoc is a pioneer in prescription apps, and its DiabetesManager system collects data on a patient's diet, blood sugar levels, and medication which can be linked wirelessly to glucose monitors. The app then advises the patient on things like the best food after a low blood-sugar reading, and can send clinical recommendations to the doctor.

Clinical trials showed that the app significantly reduced diabetes patients' blood sugar levels, and the FDA gave clearance for DiabetesManager to operate as a medical device. So far a total of ten apps have obtained FDA approval. Industry group Continua Health Alliance is developing standards for compatible formats among medical apps, and the issue of apps working only on certain types of phones also needs to be addressed. There are also apps that try to skirt federal regulation with lots of disclaimers, and many say some apps violate regulations with untested medical claims. So far the FDA is waiting until its guidelines are in place before going after those dubious apps, as it does not want to stifle innovation and is only going to regulate those apps that make clinical or diagnostic decisions.

From the article of the same title
New York Times (08/19/12) Brustein, Joshua
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Synthes Recalls Bone Putty Over Fire Risk
Synthes initiated a Class I recall of its hemostatic bone putty in July because of its potential to ignite during certain surgical procedures. The product is designed to halt bone bleeding resulting from injury or surgery, but it can catch fire when it comes into contact with electrosurgical cautery systems, according to a recall notice from the Food and Drug Administration. Synthes ordered the recall for product lots circulated between December and June, and it requested that providers cease using and return the putty to the manufacturer.

From the article of the same title
Modern Healthcare (08/21/12) Kutscher, Beth
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Will Smart Pills, Cash Boost Drug Compliance?
A variety of new strategies are being devised to tackle the problem of getting patients to take their medications as directed, as drug noncompliance costs billions of healthcare dollars per year. A “smart pill” that tracks when each pill is taken is one such strategy, as are cash incentives and games. The smart pill, called the Ingestion Event Marker, is a sensor the size of a grain of sand that is placed inside a pill or other medication and is activated by stomach fluids. It sends a signal to a water-resistant patch worn on the torso, and the data is sent to a computer application.

Proteus is working with Novartis to add the sensor to immunosuppressive drugs for organ transplant patients and hopes to have FDA approval by 2014. It will be on the market this fall in the UK. While many experts marvel at the technology involved, some question whether it will have much effect on compliance rates. Getting more data on noncompliance is helpful, says cardiologist Dipti Itchhaporia, but she adds that doctors cannot force patients to take their medication. But the technology would at least prompt important conversations, she says. Drug adherence expert Hayden B. Bosworth adds that people may not be willing to wear a patch all day every day, and others point out that the smart pill will not be effective when people are not taking their pills because of cost.

From the article of the same title
American Medical News (08/20/12) O'Reilly, Kevin B.
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