News From ACFAS

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Only a few days are left to submit your application to serve on the ACFAS Board of Directors. If you are an ACFAS Fellow and would like to help lead the profession, be sure to submit your application by Sunday, September 14 at 11:59 pm (CDT).

Visit acfas.org/nominations for details on application submission or you may also email Executive Director Chris Mahaffey for more information. Contact Nominating Committee Chair Jordan Grossman, DPM, FACFAS, (330) 344-1980, for questions regarding eligibility criteria.

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. If you have not yet applied for the ACFAS Clinical and Scientific Research Grant, now is your chance. The September 15 deadline is fast approaching, so be sure to submit your application today at acfas.org/grant. Remember that all research must be clinical or laboratory-based, with clearly defined goals that meet all criteria for grant submission.

If you have always wanted to pursue a specific area of research but lacked the financial support to do so, this is your opportunity to find the help you need. ACFAS awards up to $40,000 in grant money each year to members conducting cutting-edge scientific research to advance the profession and evidence-based medicine. Visit acfas.org/grant to apply. The September-October issue of the Journal of Foot & Ankle Surgery (JFAS) is now available and includes in-depth articles on everything from ankle and metatarsal fixation methods to foot and ankle tuberculosis in Turkey. Just log in to the ACFAS website and visit the JFAS landing page to read this and past issues.

This instant access to the latest original research, case reports, reviews and more is what makes JFAS our most popular member benefit. And don’t forget, new articles are always posted under Articles in Press as soon as their proofs have been approved—even before they’re assigned to an issue. Plus, you can tap into a fully searchable online archive of JFAS articles dating back to 1995.

So no matter if you're staying informed of the present or researching the past, use your free member access to take advantage of everything JFAS has to offer!

Foot and Ankle Surgery

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A new study published in International Orthopaedics found that minimally invasive reduction and percutaneous fixation (MIRPF) is associated with fewer wound-healing problems, better functional outcome and earlier return to work when compared with open reduction and internal fixation (ORIF) in managing displaced intra-articular calcaneal fractures. The randomized trial included 45 fracture patients who were followed for at least one year.

Of the 23 heels in the ORIF group, seven (30 percent) had wound-healing problems, compared with none in the MIRPF group (p=0.005). There was no statistically significant difference in radiological outcomes between groups, as measured by Böhler’s angle, Gissane’s angle and Score Analysis of Verona (SAVE). Median time to return to work was two weeks earlier (p=0.004) and the functional outcome score (Creighton Nebraska Health Foundation scale) at one year of follow-up was better (p=0.013) following MIRPF compared with ORIF.


Researchers examined the use of magnetic resonance imaging (MRI) in pre-operative evaluation of the anterior talofibular ligament (ATFL) in patients with chronic ankle instability (CAI). They studied 39 patients with symptomatic CAI whose maximum ATFL diameters were measured using pre-operative T2-weighted MRI with 3mm slices. The ATFL diameters were classified as normal, thickened, thin or absent. The imaging results were then compared to the gold standard macroscopic results. The researchers found complete agreement between the two: 10 thickened and 29 thin or absent. The researchers concluded that MRI can be a valuable pre-operative assessment tool for assessing the ATFLs of patients with CAI.

Practice Management

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It is important to have a clear process for creating and implementing medical practice policies. Physicians should know who in the practice is responsible for making rules, and if policies are not dealt with quickly and directly, employees may take matters into their own hands. Most employees do not have the information or experience necessary to establish policy safely, effectively and legally. If a policy change is being considered due to the behavior of one employee, the physician should deal directly with the worker instead of creating new rules.


The process of onboarding involves getting new hires adjusted to the social and performance aspects of their jobs quickly and seamlessly, and the degree to which practices make new hires feel welcome and ready reflects how fast they will be able to be productive and contribute to the practice's mission. The four levels or building blocks of onboarding are compliance, which is the lowest level and includes educating employees on fundamental legal and policy-related rules and regulations; clarification, which guarantees that employees understand their new jobs and all associated expectations; culture, which includes giving employees a sense of both formal and informal organizational norms; and connection, which refers to the relationships and information networks that new employees must establish. Practices common to an effective onboarding policy include:

1) A formal orientation program and a written plan to clearly communicate expectations and goals expected of new hires.

2) Before an employee's first day on the job, the practice can set up a comfortable work area and supply the necessary resources, such as paper, pens, computer, printer, phone, keys and business cards.

3) Set up any voicemail, email and other technology accounts.

4) Ensure the new hire feels comfortable with the directions to the office, parking, public transportation, expected arrival time, dress code and so on.

5) Place a copy of an organization chart, employee handbook, administrative forms, staff list and important phone numbers on the new employee's desk.

6) Provide practice swag such as a company pin, T-shirt, coffee mug, etc.

7) Take the hire on a tour of the office and point out key areas.

8) Introduce the employee to other staffers.

9) Treat the employee to lunch on his or her first day with a group of staff members.

10) Set up a meeting with the employee’s supervisor for the first afternoon to go over the responsibilities of the position and to give an overview of what the first month on the job will look like.

11) Not long after the new employee goes on the job, the practice manager can assign him or her to a mentor or coach.

12) If the new hire is in a supervisory role, the manager should make sure he or she meets with any direct reports one-on-one and as a group in the first week in order to build the team.

13) Schedule meetings so new employees also can meet with staffers who may not be on their immediate team.


Physicians who want to optimize the use of their practice's patient portal should look to themselves to make sure they use the portal effectively. According to a survey from Manhattan Research, about 25 percent of physicians or their teams communicated with their patients through a portal last year, a figure that is likely to increase. Physicians should consider the impact a portal will have on workflow, and setting up a portal should be a team effort. If the physician uses the portal often, patients will become more engaged. Registration should be simplified and messaging should be secure.

Health Policy and Reimbursement

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Lower costs for medical services and labor have reduced the 10-year projected cost of Medicare and Medicaid by $89 billion, according to the Congressional Budget Office (CBO). Medicare spending is predicted to decrease by $49 billion, which is less than 1 percent, from 2015 to 2024, and Medicaid spending is expected to drop by $40 billion, about 1 percent over the next decade. Despite the long-term projected drop, federal spending for major healthcare programs will increase this year by $67 billion, about 9 percent. The biggest increase will be in Medicaid, which is expected to expand by $40 billion, or 15 percent. Most of the short-term increase is due to the Affordable Care Act, including Medicaid expansion and the financial assistance used to help people buy health insurance. More than half of states and the District of Columbia have chosen to opt-in for the health law's Medicaid expansion. Subsidies to help individuals purchase health insurance on online marketplaces, and other related expenses, primarily grants to states to set up exchanges, will total $17 billion this year, according to CBO.


Hospitals and eligible professionals will now have more flexibility in meeting meaningful use requirements for the electronic health record incentive program. The U.S. Centers for Medicare and Medicaid Services recently finalized a rule providing a longer timeline and greater flexibility in meeting the goals of the 2009 HITECH Act, which provides stimulus funding for electronic health records. Providers now have an extra year to use 2011 Edition software, and the beginning of the third stage of meaningful use for the first cohort of adopters has been pushed back to Jan. 1, 2017.


The Centers for Medicare & Medicaid Services (CMS) is highlighting the patient engagement requirements of meaningful use in a recent spotlight on the Electronic Health Record Incentive Programs for eligible professionals (EPs). As the federal agency notes in its guidance, patient electronic access is both a component of Stage 1 Meaningful Use in 2014 and Stage 2 whenever that happens to begin for eligible providers given the flexibility of meaningful use this year as a result of a recently finalized rule. For more information on the Patient Electronic Access objective, review the 2014 Stage 1 and Stage 2 specification sheets and the Patient Electronic Access tipsheet.


The Centers for Medicare and Medicaid Services (CMS) has announced that it will once again take the Open Payments database, which details payments made to physicians by drug and device companies, offline for maintenance. The database, developed as a result of the Physician Payments Sunshine Act, has had several recent problems, including going offline to resolve a problem that was switching records for physicians with similar names, and a data integrity problem, which prevented data on payments made indirectly through contract research organizations from being posted online. The American Medical Association (AMA) says the most recent shutdown adds to growing concerns that the site is not ready for the public. CMS says it is still committed to having the database open to the public on September 30, but the AMA and 100 other physician groups have been pushing for a delay to give physicians more time to register and review the accuracy of their data. AMA president Robert Wah, MD, says patients need accurate information, and if the government releases inaccurate information to the public, it can result in misinterpretations and damaged reputations and can cause patients to question their trust in their physicians. The AMA is asking for a six-month extension before the data is released to the public.

Medicine, Drugs and Devices

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A new study published online in the American Journal of Preventive Medicine finds that screening everyone over the age of 35 for Type 2 diabetes would identify more undiagnosed cases at only marginally greater cost than the use of current guidelines. Researchers at the Palo Alto Medical Foundation Research Institute used data gathered from the National Health and Nutrition Examination Survey to compare the cost and efficacy of universal screening at 45 and the two leading guidelines: those of the U.S. Preventive Services Task Force (USPSTF) and the American Diabetes Association (ADA). Just over 80 percent of non-pregnant, diabetes-free adults in the data set met the ADA screening guidelines, compared to 28.2 percent who met the USPSTF guidelines. Seventeen people would have to be screened to identify one person with diabetes under the ADA guidelines, 14 under the USPSTF guidelines and 15 under universal screening of those 35 and older. The ADA guidelines would miss 15 percent of undiagnosed diabetes in those 35 to 44, and the USPSTF guidelines would miss 61 percent of diabetes in those 35 and older. Based on Medicare fee schedules, universal screening would be only slightly more expensive, leading the researchers to conclude that, "... it may be time to harmonize guidelines and recognize universal screening for diabetes in adults aged 35 years (and older) as formal policy."


A new study casts doubt on the prognostic value of two of the leading clubfoot severity grading systems. Researchers sought to evaluate the Dimeglio score and Pirani score by analyzing their correlation with the number of Ponseti casts required to achieve initial clubfeet correction. The researchers carried out a retrospective study of all clubfeet assessed at a single clinic between January 2007 and December 2011. The clubfeet were all scored using both Pirani and Dimeglio, and the number of Ponseti casts was calculated from the first cast up to the initiation of foot abduction orthosis. Only a low correlation was found between Dimeglio scores and the number of casts, while no correlation was identified between Pirani scores and the number of casts. This finding suggests that both scoring systems have questionable prognostic value, at least in the early stages of treatment.


Researchers report that 2-carba-cPA (2ccPA), a chemically stabilized derivative of cyclic phosphatidic acid (cPA), relieves the pain experienced due to osteoarthritis (OA) symptoms. cPA is a naturally occurring phospholipid mediator that inhibits chronic and acute inflammation. 2ccPA has also been found to attenuate neuropathic pain. Japanese researchers sought to test 2ccPA's effectiveness in relieving OA pain in animal models, delivering twice-weekly intra-articular injections of 2ccPA to rabbits with OA induced by total meniscectomy in the knee joint. The injections significantly reduced pain and articular swelling, and histopathology showed that it suppressed cartilage degeneration linked to OA. The researchers also examined 2ccPA's effects on the inflammatory and catabolic responses of human OA synoviocytes and chondrosarcoma cells in vitro. They found that 2ccPA stimulated synthesis of hyaluronic acid and suppressed production of metalloproteinases MMP-1 and -13.