News From ACFAS

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Help shape the future of ACFAS’ CME by participating in our triennial CME survey. Your input will help us align our CME offerings around your needs for the next three years.

The survey will arrive to you via email from ACFAS with the subject line “Shape the Future of Surgical CME!” Respond to the survey by September 15 and be eligible to win one of four $200 American Express gift cards. Your responses will be confidential and reported in the aggregate only. Learn the dos and don’ts of tendinopathy and get practical solutions for your toughest hammertoe cases in our newly released clinical sessions, Understanding Tendinopathy: Things That Work and Things That Don’t and The Hammered Toe.

These free sessions, available at acfas.org/e-learning, include individual presentations with recognized experts who explain which treatment options and procedures work best for them and why. A brief exam is included after each session so you can earn CPME CE credits. Visit the full clinical session library for more topics and be sure to check out our Arthroscopy of the Foot and Ankle e-book, podcasts, Surgical Techniques DVDs and other e-learning products. The College’s only official housing partner is OnPeak, LLC. Hotel poachers, or organizations that falsely represent themselves as our official housing partner, are unauthorized third parties not related to ACFAS 75. If anyone other than onPeak contacts you, do not give them your credit card information or a cash deposit.

The safest and most secure way to reserve your room for the conference is through acfas.org/asc. Attendees are guaranteed the lowest hotel rates available.

Exhibitors: If any unauthorized parties try to sell you attendee lists for ACFAS 75, contact us immediately. The ACFAS Fellowship Committee recently determined the following fellowships exceed the minimal requirements to be upgraded to Recognized Status with the College after their first successful year:

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

North Jersey Reconstructive Foot and Ankle Fellowship, Lyndhurst, New Jersey
Program Director: Michael Subik, DPM, FACFAS
acfas.org/fellowshipsubik

Foot and Ankle Fellowship of South Florida, Plantation, Florida
Program Director: Warren Windram, DPM, FACFAS
acfas.org/fellowshipwindram

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

Palo Alto Foundation Medical Group—Santa Cruz Foot and Ankle Fellowship, Palo Alto, California
Program Director: Timothy Blakeslee, DPM, FACFAS
acfas.org/fellowshipblakeslee

Reconstructive Foot and Ankle Surgery Fellowship, Louisville, Kentucky
Program Director: Syed Khader, DPM, FACFAS
acfas.org/fellowshipkhader

NOFA Foot and Ankle Reconstruction Fellowship, Concord, Ohio
Program Director: Jonathan Sharpe, DPM, FACFAS
acfas.org/fellowshipsharpe

Allegiance Foot and Ankle Surgery Fellowship, Jackson, Michigan
Program Director: Tudor Tien, MD
acfas.org/fellowshiptien

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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A recent study aims to define normal values for ankle dorsiflexion (ADF) using a standardized examination procedure in order to diagnose impaired ADF and m. gastrocnemius tightness (MGT). Investigators examined 64 asymptomatic subjects to assess bilateral ADF with knees extended and flexed and either nonweightbearing or weightbearing. Average ADF values with the knee extended were 22.7° ± 5.9° not bearing weight and 33.3° ± 5.5° bearing weight. Physiological side differences with the knee extended were less than 6°, and knee flexion resulted in an approximate ADF increase of 10°. This examination procedure allows for the definition of a decision pathway to diagnose impaired ADF and MGT.


Researchers evaluated the usefulness of diffusion tensor imaging (DTI) to complement conventional MRI in the study of the sciatic nerve and its pathologies. Seventeen patients with sciatic neuropathy and 10 healthy controls underwent an MRI and a DTI study in a 3-T MR scanner. In the patient group, the affected sciatic nerves had significantly lower fractional anisotropy values and higher apparent diffusion coefficient values than the controls. When compared with conventional MRI, DTI showed higher sensitivity in detecting nerve damage. In all cases, DTI offered complementary information and confirmation of the suspected pathology.


Skeletal changes related to McCune-Albright syndrome (MAS) tend to be severe due to the polyostotic form of the disease. Trendelenberg gait and limited mobility are the most common presenting features. In this study, researchers recruited one boy and four girls (7–16 years) in their departments from 1998 to 2012 with the pathology. Limb length discrepancy was the main clinical presentation. Repetitive microfractures caused the development of "shepherd crook" deformity with pain, representing the main burden. They found that the tendency toward progressive unilateral lower limb deformity in patients with MAS was usually associated with thinning and expansion of the cortex and distortion of the normal lower-limb integrity secondary to repetitive microfractures. The researchers referred to realignment valgus osteotomy with internal fixation to preserve proper alignment. Moreover, guided growth technique with 8-plates was performed in one case. The latter is a situation that warrants surgical treatment to realign the deformity and to preserve function. Prophylactic intramedullary nailing via the application of locking nails to ensure stabilization of the femoral neck was found to be effective. However, the mosaic nature of MAS means any cell, tissue and organ in any site of the body could be affected to varying degrees. The clinical manifestations show the diverse nature of the disorder ranging from mild clinical signs to severe life-threatening disease, the researchers observed.

Practice Management

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An effective search engine optimization (SEO) strategy increases the search engine ranking and web presence of a practice’s website, which can dramatically influence digital consumers’ healthcare selections. In a survey conducted by Google and Compete Inc, 84 percent of patients use both online and offline sources to research practices. Online searches drive three times as many visitors to practice websites compared to nonsearch visitors, and 44 percent of patients who research practices on mobile devices scheduled an appointment. An effective SEO strategy involves an understanding of keyword searches and analysis, website analytics and content optimization. Because most online users will not look beyond the first page of search results when conducting online practice research, it is important to compete for the most prominent rankings.


Making small cost cuts can help medical practices save money and resources while enhancing services. Buying supplies in bulk and as part of a larger purchasing group can help practices save, as can specialty associations that offer member discounts and purchasing programs. As technology prices fall, practices should actively renegotiate contracts for technology and telecommunications products and services, possibly by extending agreements in exchange for lower prices. Practices can also stay on top of benefit cost hikes by shopping out contracts for health, disability and malpractice insurance every year. Payroll and payment processing systems can be streamlined by switching to a dedicated payroll company and choosing less expensive payment processing networks. Practices that have implemented a billing-free payment policy, which requires patients to leave a credit card on file, are seeing significant savings in costs and productivity. Additionally, student externships could offer an inexpensive staffing solution to practices, as students can shadow physicians and enter chart information for little to no cost. A way to trim overhead costs is to move business functions, like billing departments, to less expensive office space. Finally, obtaining low-cost and donated items and services for patients, such as lotions, puzzles and music, can improve patient satisfaction scores.


Critics of electronic health records (EHRs) argue that decreasing the use of EHRs or fundamentally changing the system could actively enhance care. Such critics assert that physicians need to focus their attention on the patient and look away from the EHR screen during appointments to better assess the patient on an individual level and catch symptoms that may not have been recorded in the EHR. EHR systems have lagged behind technology trends and have yet to successfully integrate and synthesize information in a useful way. Many EHRs are beginning to incorporate predictive analytics but lack functions that would allow providers to compare similar patients when determining a diagnosis and treatment plan. Critics claim EHRs are currently obstacles to quality healthcare because they have not been integrated seamlessly into physician workflow. Additionally, the influx of disorganized data produced by EHRs lead to multiple alerts and reminders that are often ignored by providers. By adopting new methods to prioritize reminders and collect and represent patient data, EHR developers can make these tools more functional within a practice.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services has disclosed its list of hospitals that received nearly $1.5 billion total to resolve a longstanding Medicare billing dispute. The payout settles 346,000 claims for reimbursement for treating Medicare patients admitted on or before October 1, 2013, following the government’s offer in 2014 to pay hospitals 68 percent of the value of the claims that had been caught in a backlog of appeals. The settlement indicates that many hospitals preferred to settle quickly for a discounted amount rather than wait for a lengthy appeals process. More than 2,000 hospitals benefited from the government payout, with 35 hospitals receiving more than $5 million each. New York Presbyterian Hospital topped the list, receiving nearly $16 million.


The U.S. Centers for Medicare and Medicare Services (CMS) has released data on the prescription drugs that the program covered under the Medicare Part D Prescription Drug Program in 2014. CMS says the data shows which prescription drugs were prescribed to Medicare Part D enrollees by healthcare professionals. The data also has information from more than a million providers who prescribed a total of $121 billion in drugs covered by Medicare Part D. That is a 17 percent increase compared to data from 2013. The recent data release also contains information on opioids, antibiotics, antipsychotics, and other high-risk medicines.


The U.S. Centers for Medicare and Medicaid Services will end its grace period for ICD-10 claims on October 1, a year after the new set of diagnostic codes went live. The grace period applied to claims submitted to Medicare and Medicaid and allowed providers to use codes in the correct treatment family. After October 1, providers will be required to use the correct degree of specificity in their coded claims. ICD-10 contains more than 70,000 diagnostic codes, replacing the ICD-9 set’s 11,000 codes. Healthcare providers were initially concerned that the increase in codes would lead to more incorrect claims and subsequent denials, but the rate of denials has been practically unchanged since the new set was rolled out last year.

Medicine, Drugs and Devices

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The Association of periOperative Registered Nurses (AORN) says the guidelines on operating attire issued by the American College of Surgeons (ACS) are problematic and not based on evidence. Included in the ACS guidelines is a note on the symbolism of skullcaps to the surgical profession and a recommendation to cover all but a “limited amount of hair” or a “modest sideburn.” Director of Evidence-Based Perioperative Practice Lisa Spruce says ACS guidelines are difficult to define and enforce, and operating attire should not be based on symbolism. "Regulatory agencies, accrediting bodies and patients expect healthcare organizations to follow guidelines that are evidence-based rather than recommendations based on professionalism, common sense or decorum,” states AORN's response to the ACS guidelines. Other discrepancies include the procedure for changing from soiled scrubs and attire to work clothes outside of the operating room. AORN notes that it has already released its own set of guidelines for surgical attire that has been accepted by the AHRQ National Guidelines Clearinghouse.


Pharmaceutical and medical device companies are continuing to pay doctors for promotional speaking and advising roles after they have been disciplined for serious misconduct, according to ProPublica. Disciplinary records for doctors in five states were checked against data released by the U.S. Centers for Medicare and Medicaid Services on company payments to doctors, including payments for speaking, consulting, education and travel. ProPublica’s analysis identified at least 2,300 doctors who continued to receive industry payments between August 2013 and December 2015 despite records of misconduct. Hundreds of the physicians in question were sanctioned for severe offenses, such as providing poor care, inappropriate prescriptions, cheating public insurance programs and sexual misconduct. More than 180 had their licenses temporarily suspended or restricted, and at least 40 physicians’ licenses had been revoked or surrendered permanently. At least 400 pharmaceutical and medical device makers were found to have made payments to doctors after they were disciplined by state medical boards. After a 2010 ProPublica study focusing on the payments made by seven drug companies, major pharmaceutical companies, such as Pfizer and AstraZeneca, promised to revise their vetting process. However, few drug and device makers currently offer details on what checks are run and how often doctors are screened.


An analysis by the Financial Times found that U.S. doctors are wasting hundreds of millions of dollars every year by prescribing costly branded medicines. According to the analysis, major drug manufacturers have earned more than $1 billion in the first six months of 2016 by selling expensive medicines that have lost patent protection. Pharmaceutical companies argue that the high prices are due to a shortened shelf life caused by cheaper alternatives entering the market. Meanwhile, doctors say they are hesitant to use generic drugs when they have settled on a particular medicine already. The issue has also become a major topic on the presidential campaign trail with Hillary Clinton saying she would address the issue if elected president of the United States.