News From ACFAS

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The deadline for submitting applications to serve on the ACFAS Board of Directors has been extended to Sunday, September 14 at 11:59 pm (CDT). If you are an ACFAS Fellow and believe you are qualified to serve on the board, submit your application now at acfas.org/nominations or email it to Executive Director Chris Mahaffey.

Questions regarding eligibility criteria should be directed to Nominating Committee Chair Jordan Grossman, DPM, FACFAS, (330) 344-1980.

The Nominating Committee will announce recommended candidates to the membership no later than October 23, 2014. Candidate information and ballots will be emailed to all voting members no later than December 7, 2014. Electronic voting ends on January 6, 2015. New officers and directors take office during the ACFAS 2015 Annual Scientific Conference, February 19-22, 2015 in Phoenix. Tuning in to an ACFAS podcast is one of the best ways to connect with your peers and the profession. Our podcast moderators and panelists cover the latest industry perspectives, and new podcasts are added to ACFAS’ e-Learning Podcast Library every month.

Listen to our September 1 podcast release, “Amputations: TMA or Selective Forefoot Amputations,” featuring moderator Allen M. Jacobs, DPM, FACFAS, to learn the risks and benefits associated with each procedure, then check back on September 15 to hear “The Challenging Patient” with moderator Stephen Schroeder, DPM, FACFAS.

More podcasts will be released throughout the remainder of 2014, so be sure to visit the Podcast Library often to hear why our podcasts always get people talking! Want to earn 12 continuing education contact hours close to home in just two days? Register today to attend any one of six Advanced Forefoot Reconstruction and Complications programs between now and the end of the year. As part of ACFAS’ popular ACFAS Coming to You series, these hands-on workshops and seminars give practicing and in-training surgeons alike the opportunity to hear other experienced doctors discuss innovative surgical approaches and techniques.

Each program kicks off on Friday evening with a presentation on how to handle common forefoot surgical complications followed by a review of participants’ case studies. Saturday brings a full day of workshops, labs, lectures and panels to examine problematic cases.

This is your opportunity to further your education, make new connections and refine your skills. Find the city nearest you and register today at acfas.org/comingtoyou.

Foot and Ankle Surgery

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A study was conducted to characterize the gait biomechanics of patients who underwent total ankle arthroplasty. The research involved the retrospective evaluation of 17 patients suffering end-stage osteoarthritis of the ankle who underwent an ankle replacement between March 2006 and May 2011. Clinical, radiological and biomechanical gait parameters were assessed with the NedAMH/IBV dynamometric platform. The American Orthopaedic Foot and Ankle Society (AOFAS) score improved from 31 to 83 with a high rate of satisfaction at the last follow-up, while kinetic gait parameters were more similar to a healthy ankle. A radiolucent line was detected in eight patients without any incidence of subsidence.


A short-term study has found that a hybrid third-generation minimally invasive surgical (MIS) technique for correcting symptomatic hallux valgus is safe and produces good clinical outcomes. The technique, which combines first- and second-generation MIS techniques with the use of a distal chevron osteotomy and a screw to achieve better control and stabilization of the metatarsal head, was used to treat 45 consecutive feet. The study's authors followed up with patients six to 17 months after surgery and found that patients displayed significant improvements in all three domains of the Manchester-Oxford Foot Questionnaire (MOFXQ). Significant improvements were also seen in all of the radiographic measures that were assessed, including hallux valgus angle (HVA) and intermetatarsal angle (IMA). Average HVA decreased from 30.54 degrees to 10.41 degrees, while mean IMA decreased from 14.55 degrees to 7.11 degrees. In addition, the authors found that the shortening of the first metatarsal had no effect on clinical outcomes. The rate of complications was very low.


A new study has found that unenhanced magnetic resonance (MR) angiography using flow-sensitive dephasing (FSD)-prepared steady-state free precession (SSFP) is useful in assessing foot arteries and detecting significant arterial stenosis in diabetics. The study involved 32 healthy individuals and 38 diabetics, all of whom underwent unenhanced MR angiography with a 1.5-T MR unit. The study's authors found that the use of unenhanced MR angiography yielded 92 percent of diagnostic arterial segments in the diabetic group and 95 percent of diagnostic arterial segments in the group of healthy patients. The difference between these percentages was not significant. In addition, the study found that unenhanced MR angiography had an average accuracy rate of 92 percent. The study concluded that unenhanced MR angiography clearly displayed the foot arterial tree and was also able to accurately detect arterial stenosis. The technique was also determined to be safe.

Practice Management

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The U.S. healthcare industry faces the challenge of marketing to Hispanic consumers with unique purchasing behaviors. More Hispanics than non-Hispanics employ social media, mobile apps and Internet searches to find information about physicians and insurance companies, according to a new PwC report. Moreover, Hispanic consumers usually opt out of landline phones and computers, relying primarily on cell phones for online usage. Strategies that practices can follow to attract Hispanic patients include:

1) Using social media. Practices should not only post several times a day to their social media channels in English, but also incorporate Spanish messaging. They also should consider using an online translation service to translate posts ahead of time if their budget precludes hiring a Spanish translator.

2) Employing mobile apps. Such apps make it fast and easy for people to access health information from the practice. Practices should supply an app that is easy to navigate and preferably with a Spanish language option.

3) Updating online listings with all major search engines.

4) Ensuring the practice's website is readable and navigable on the smaller screens of mobile devices.

5) Offering Spanish language options in both print and electronic communications. Practices should bear in mind that developing separate advertising efforts for Hispanic and non-Hispanic populations can be very expensive, and they should alternatively use bilingual messaging to appeal to both markets within a single ad.

Furthermore, investing additional time in customer care can foster sustainable patient growth numbers among the Hispanic populace.


It is a common practice for physicians and staff to send text messages to patients, without being aware of or ameliorating the risk. Standard Short Message Service (SMS) texting is unencrypted and insecure and is not HIPAA-compliant. Texting with patients carries the risk of data breaches, security hacks and HIPAA violations. Practices should follow a number of precautions that include:

1) Pausing all texting until a clear set of risk reduction policies is in place and an attorney has been consulted. The practice should politely notify text-using patients that the hiatus is for their protection and privacy.

2) Deploying encryption on all mobile devices. Not only is encryption inexpensive and straightforward, but encryption software is particularly valuable when texting patients because it lowers the risk of unauthorized parties accessing text and other data on a physician's or staff's mobile device.

3) Developing a text usage policy that features details such as who is authorized to send/receive texts from patients, message response times, appropriate and inappropriate topics for text messaging, how a critical text will get escalated and how data from text messages is included in the patient record. The practice also should confer with a healthcare attorney to refine a policy that reflects the laws in its state, and then ensure all staffers are trained to follow it.

4) Developing a Statement of Understanding for patients who use text messaging. This statement will articulate the innate risks of unsecured messaging, such as the inability to confirm the recipient, no way to escalate an urgent message and no secure archive for messages. The statement should let patients know they can revoke permission to text using an unsecured messaging system at any time, and patients should be asked to review and re-sign the policy every 12 months.

5) Investigating secure text messaging solutions, which are encrypted and transmitted across a secure network. Messages are usually stored in the cloud on a secure, encrypted server, enabling them to be printed, ported to an electronic health record, archived and stored for security audit and medical record management purposes.


Experts say that physicians' practices that want to remain independent need to pay close attention to their financial viability, which is increasingly under threat from regulations such as the Affordable Care Act and the mandated switchover to ICD-10. One area that experts advise practices to focus on is their front desk staff, which plays an important role in obtaining reimbursements and ensuring that online reviews of the practice are generally favorable, both of which can impact a practice's bottom line. Experts say that front desk staffers should make patients feel welcome while also handling insurance verification and accepting copayments in an organized manner. Steven Peltz of Peltz Practice Management and Consulting Services says practices should be sure to train their front desk staff to perform these tasks well or risk having to spend time and effort recruiting new staffers.

Practices should also be sure to put strong financial controls in place to keep track of the funds being deposited into bank accounts so any fraudulent activity by employees can be identified quickly, experts say. In addition, practices should ask for increased reimbursements from insurance companies. Even a 3 percent annual increase in reimbursements can make a significant difference, one expert says. Finally, experts advise practices to improve the productivity of employees who are not keeping up with their colleagues, as doing so can help keep labor costs under control.

Health Policy and Reimbursement

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Pennsylvania Gov. Tom Corbett has reached a deal with the Obama administration to extend the state's Medicaid program to half a million low-income residents under the Affordable Care Act. Pennsylvania is now the 27th state to agree to broaden Medicaid to include everyone earning up to a third more than the federal poverty level, or around $16,000 for a single adult. The agreement makes Corbett the ninth GOP governor to go along with a central part of the 2010 healthcare law. The deal represents a boost for the federal government in its efforts to coax reluctant states to extend their programs in the wake of a Supreme Court decision in June 2012 that allowed them to opt out of expansion.


A new report from the Center for Healthcare Quality and Payment Reform's Harold D. Miller says the system of physician accountability for services used by some Medicare demonstration projects, accountable care organizations (ACOs) and commercial health plans is unfair to doctors. Under the system, doctors who treat patients who also visit a number of other healthcare providers over the course of a year are assigned those patients' healthcare costs and quality scores if they saw those patients more times than the other providers.

The system is designed to reward doctors for achieving higher-quality care that can lead to better patient outcomes and encourage them to keep costs down. But Miller says the system is unfair because doctors can be penalized for high-cost and/or low-quality care given by other providers. Those penalties take the form of cuts to Medicare physician fee schedule payments that start off at 1 percent but could rise to as high as 9 percent by 2021. Miller adds that the system could also inadvertently encourage doctors to avoid seeing patients with some high-cost conditions, particularly if patients may see another provider by the end of the year. The use of the system is scheduled to be gradually broadened, applying to physicians in practices with 100 or more eligible professionals beginning in January before being applied to all doctors by the beginning of 2017.


A new report that discusses the results of efforts to reign in costs and improve healthcare quality under the Medicare Physician Group Practice Demonstration could be used by the Centers for Medicare and Medicaid Services (CMS) to modify the accountable care program. The report found that the Medicare Physician Group Practice Demonstration, which was the precursor of the affordable care program, was largely successful at driving down Medicare spending. The 10 participating medical groups reduced Medicare spending by 2 percent per person per year during the five-year demonstration. Medical groups took a two-pronged approach to reducing spending: focusing on hospitals, which are the most expensive place to treat patients; and patients with complex conditions, those who are chronically ill and those who are vulnerable to illness, all of whom are the most expensive to treat.

The report also noted that the quality of care provided to patients improved overall, even at providers that saved the most money under the demonstration. One observer says these and other findings show that changes to the affordable care program could allow cost-saving strategies used by those who participated in the demonstration to flourish. The observer says one modification that could be included in CMS' proposed rule for altering the program could help providers and patients know who will be receiving care under an accountable care organization so doctors can better educate and encourage their patients.

Medicine, Drugs and Devices

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Elastic compression using ankle injury stockings (AIS) can help improve functional outcomes and quality of life in patients who suffer ankle fractures and are treated either surgically or conservatively, a new study has found. The study involved 31 patients who were treated surgically within 72 hours after seeking treatment, while 59 were treated conservatively during the same time frame. All patients were randomized to be treated with compression by AIS plus an Aircast boot or Tubigrip plus an Aircast boot. Patients in the AIS compression group experienced reduced ankle swelling at all time points. The average Olerud-Molander ankle score (OMAS) in the AIS group was 98 at six months, compared to an average of 67 in the Tubigrip group. AIS compression also resulted in significant improvements in the average American Orthopaedic Foot and Ankle Society (AOFAS) and Short Form (SF)-12v2 Quality of Life score after six months. Patients in the Tubigrip group experienced deep-vein thrombosis (DVT) more frequently, although a larger study is needed to determine whether AIS compression helped keep DVT rates down in the patients who were treated with this method.


The non-steroidal anti-inflammatory drug (NSAID) Zorvolex has been approved by the Food and Drug Administration (FDA) for patients who need help managing pain caused by osteoarthritis. The drug comes in capsule form and contains submicron particles of diclofenac. The use of these particles, which are about 20 times smaller than their original size, allows the drug to dissolve more rapidly. The FDA's decision to approve Zorvolex was based on data from a 12-week, randomized, double-blind, parallel-group placebo-controlled trial involving 305 patients with osteoarthritis of the hip or knee. Patients were randomized to receive a 35 mg dose of Zorvolex twice or three times daily or a placebo.


A new study evaluated short-term clinical outcomes in patients with early-stage moderate-to-severe rheumatoid arthritis to determine their usefulness in predicting poor response after one year of treatment with either etanercept/methotrexate (ETN/MTX) therapy or MTX alone. The study found that high levels of disease activity and less improvement with treatment over time during the first 24 weeks of treatment, especially after 12 weeks, were both useful in predicting lower remission rates in patients one year after receiving either type of treatment. In addition, the study found that the rate of 28-joint Disease Activity Score-Erythrocyte Sedimentation Rate (DAS-28-ESR) remission was generally higher among patients in the ETN/MTX group than it was in the MTX monotherapy group. These higher rates of remission were seen at most timepoints between weeks four and 24.