News From ACFAS

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ACFAS is on its way to six locations across the United States with the Simple to Complex Forefoot Revisional Surgery Workshop and Seminar. Open to current surgeons and those in training, the program begins on a Friday evening with a presentation on "Common Forefoot Surgical Complications—How to Deal with Them" and continues on Saturday with a hands-on sawbone workshop where participants practice the cutting-edge techniques just learned.

Take advantage of this hands-on program in one of the following cities in 2013: Jacksonville, FL; Chicago, IL; Dallas, TX; New York, NY; and in 2014: Tysons Corner, VA; and Manhattan Beach, CA. Surgeons who are currently practicing or still in training are eligible to register to attend the one nearest you. Program attendees will earn up to 12 continuing education contact hours.

To register or for more information, visit acfas.org/comingtoyou. These courses are filling up fast, so register today. Utilize the latest edition of the FootNotes newsletter to interact with your patients and potential patients by educating them on how to keep their family's feet healthy this fall season and beyond. Download your copy at acfas.org/footnotes (member log in required) and customize it with your practice's contact information in the space provided. You can also find other practice marketing tools to help grow your practice in the Marketing Toolbox at acfas.org/marketing.

Topics for fall 2013 include:

• Don't Start off the School Year with Painful Feet
• Big Relief is in Sight for a Painful Big Toe
• Keep Your Feet Safe and Your Yard Clean

Learn from both ends of the practice spectrum this month when you download the latest free podcasts, Burning Pain and Practice Management Update. In Burning Pain, hear opinions from your respected peers on why this is such a frustrating problem to evaluate, diagnose and treat; as well as what you can look for when consulting patients who present with this problem. Practice Management Update gives valuable insight on the changes in healthcare as reform changes the focus on value over volume – a complete 180 degree change from how it's always been. Learn how ACFAS gives members a leg up on the competition during this time of evolving healthcare – as well as medical – reform from a Practice Management Committee member’s view.

To download these podcasts, visit acfas.org/e-learning and see Podcasts for the complete library.

Foot and Ankle Surgery

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Doctors in Turkey have performed a study that examined the effectiveness of a minimally-invasive surgical method for treating Achilles tendon (AT) ruptures. The study recruited 13 acute AT rupture patients who were treated using the minimally-invasive method, which is a modified version of the Achillon technique. The study concluded that the technique was successful in treating acute AT ruptures, as patients displayed good functional results and low complication rates. The average American Orthopaedic Foot & Ankle Society (AOFAS) score at final follow up was 92.5, while average calf diameters were 38.9 cm on both the operated and nonoperated extremities. Ultrasounds revealed that the site of the rupture was 46.2 mm proximal from the calcaneal insertion and that the operated side was significantly thicker than the nonoperated side. No patients experienced wound problems, reruptures, or nerve injuries, though there was one case of deep vein thrombosis. That patient was able to recover without sequelae.


A recent study has found that surgeons should use care when performing isolated tibiotalar (TT) arthrodesis to treat valgus tilted ankles in patients with stage IV adult acquired flatfoot deformity (AAFD). Researchers came to that conclusion after examining four men between the ages of 55 and 79 who underwent a successful TT fusion that involved the use of screws and plates for fixation. A final follow up revealed that all patients had experienced a progressive destabilization of the hindfoot complex that resulted in a valgus pronation deformity with flattening of the arch. All of the patients also had a highly unstable foot that was not manageable with corrective shoes and braces. The study determined that this progressive destabilization of the hindfoot complex was the result of persistent peritalar instability as well as the presence of calcaneus and navicular subluxation. Researchers also said that incompetent peritalar ligaments in patients with stage IV AAFD may not be able to hold up under the stress of the increased mechanical load that occurs following TT fusion, possibly because of persistent valgus talar tilt following fusion. The study recommended that surgeons who want to use TT fusion to treat valgus tilted ankles in stage IV AAFD patients should perform fusion in neutral or slightly varus talar positions.


A recent study compared the use of lateral transfers of the flexor hallucis longus (FHL) or flexor digitorum longus (FDL) tendons in treating concomitant, irreparable peroneal tears. The study involved nine cadavers, in which both types of tendons were transected through a medial approach distal to the knot of Henry. Each tendon was then transferred into a lateral incision, passing the FDL tendon both posterior and anterior to the tibial neurovascular bundle. Each of the tendons was also individually secured to the base of the fifth metatarsal while the foot was in maximal eversion and dorsiflexion.

Researchers found that the average FHL tendon diameter was 5.1 mm while the average FDL tendon diameter was 4.5 mm. An additional 4.9 cm of FHL tendon remained to suture to itself after it was drawn through a bone tunnel, though only 0.5 cm remained for posterior and anterior FDL transfers. The FHL tendon was found to be long enough for several fixation options, and was also seen as being a stronger muscle for transfer. The shorter length of the FDL tendon reduced the number of available fixation options. Increased muscle bulk within the retrofibular groove was not seen following the transfer of the FHL. Researchers did observe obvious visual compression of the tibial nerve with plantar flexion and inversion of the foot following every FDL transfer posterior to the neurovascular bundle.


A recent retrospective review examined the effectiveness of using two types of vascular bone transfer options, fibula flaps and medial femoral condyle flaps, at the foot and ankle. The study examined 12 patients who had been treated with vascularized bone flaps, seven of whom were treated with fibula flaps and five of whom were treated with medial femoral condyle flaps, by a senior surgeon. Researchers concluded that both types of flaps are valid options for foot and ankle reconstruction and salvage, though they found that each option is better for certain situations than it is for others. For example, medial femoral condyle flaps are the best option when a small segment of vascularized bone is needed. But fibula flaps are a better option when structural support is needed, as their large cortical surface areas provide greater rigidity.

Practice Management

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Doctors and other experts say that the use of healthcare information technology (HIT) can have a number of positive effects on the ability of doctors to provide care to their patients, though it can have several drawbacks as well. One of the benefits of HIT is that it gives doctors who typically have an average of just eight to 10 minutes for patient office visits additional options for communicating with their patients when they are not in their offices, says Dr. Geeta Nayyar, the chief medical information officer of an organization that provides video patient education programs in practice waiting rooms and exam rooms. Another advantage to using HIT is that it has made health information more readily available to patients, Dr. Nayyar says. However, Dr. Nayyar notes that patients who are used to searching Google and other Web-based forums for healthcare information need to be counseled against believing all of the information they read on the Internet. Dr. Nayyar says that it is important to direct patients to trusted sources of health information so that they are properly educated about the healthcare issues they are dealing with. Experts say that healthcare providers who make an effort to stay on top of the tools that are available to patients and use these tools as part of education efforts will continue to be at the center of patient care.


Experts say that there are a number of steps that physicians' practices must take before merging with other practices or selling out to a hospital system. Any practice that is considering a merger or sale should first consider their alignment strategy before finding a specific partner, says Medical Group Management Associates principal consultant Kenneth T. Hertz. This involves determining what the practice hopes to accomplish by merging or selling, the circumstances under which the practice would not go through with a merger or sale, and the qualities that the practice is looking for in a partner, Hertz says. Once the practice finds an appealing partner, the practice should be as open and transparent about its finances as possible in order to gain the other practice's trust, as this is the biggest obstacle to completing a deal, says Dr. Tejas Mehta, who recently took over his father's practice. After the practice has identified another practice to merge with or a hospital system to sell itself to, it must then draw up a contract that governs the terms of the sale or merger. This contract should deal with a number of issues, including governance, the distribution of earnings and expenses, and the use of electronic health records. Consultant Owen Dahl says that practices should be sure to carefully read these contracts before signing them to ensure that the final terms are the same as what was discussed.

Health Policy and Reimbursement

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The Republican-controlled House of Representative on Sept. 20 passed a continuing resolution that would fund the federal government through mid-December but would also permanently defund the Affordable Care Act--a provision that is a non-starter with the Democratic-controlled Senate and President Obama. House Republicans who spoke during the floor debate said that defunding the Affordable Care Act is necessary because the law is poised to create serious damage to the nation's economy, while House Democratic Whip Steny Hoyer (D-Md.) spoke out in favor of the law and accused the GOP of having a "destructive obsession" with its repeal. The Senate is set to take up the measure passed by the House this week, though both Senate Majority Leader Harry Reid (D-Nev.) and Sen. Orrin Hatch (R-Utah) have said that the bill will not pass the upper chamber. But Sen. Ted Cruz (R-Texas) has vowed to do anything necessary to defund the Affordable Care Act, possibly including a filibuster. Even if the Senate did pass the legislation, it would be vetoed by President Obama.


Dr. Peter Basch, the chairman of the American College of Physicians' medical informatics committee, has sent a letter to the Office of the National Coordinator for Health Information Technology expressing concern about the Department of Health and Human Services' criteria for meaningful use of electronic health records. Basch wrote that ACP supports the program's goals but that it is concerned about a number of aspects of the plan, including the "appropriateness, focus and feasibility of some of the proposed measures." ACP is also concerned about any unintended consequences and additional costs that doctors' practices will have to contend with as a result of the meaningful use requirements, the letter said. Basch went on to say that meaningful use has become less relevant to internal medicine subspecialists as it has become more prescriptive of certain work flows. Basch called for the meaningful use requirements to take a less prescriptive approach, and added that his organization believes doctors should be given more time to report Stage 2 measures and develop the advanced clinical processes that will be needed. Stage 3 should continue to be focused on improving patient outcomes, Basch said.


A new report from the Ponemon Institute has found that medical identity theft is on the rise, and that this growing problem could be having an effect on patients' relationships with their healthcare providers. The Ponemon Institute found that the estimated number of medical identity theft victims reached 1.8 million this year, an increase of 19 percent over the 1.5 million medical identity victims in 2012. The report also found that 56 percent of the 788 adults who were surveyed, all of whom had either been a victim of medical identity theft themselves or who had a family member who had been victimized, believed that the most likely result of medical identity theft was a loss of trust and confidence in their healthcare provider. That was up from the 51 percent of respondents who gave that answer in last year's survey. But although medical identity theft is a growing problem, and a majority of the survey's respondents said they believed that the crime had negative consequences, the survey also found that half of respondents were not doing anything to prevent their identities from being stolen again. In addition to surveying the attitudes of medical identity theft victims, the report also included recommendations for healthcare organizations and government agencies to prevent medical identity theft, including improving authentication procedures.


Medical Group Management Association-American College of Medical Practice Executives (MGMA-ACMPE) has released a report harshly criticizing the Centers for Medicare & Medicaid Services (CMS) for its proposed rule for the 2014 Physician Fee Schedule. One of the aspects of the proposed rule that MGMA-ACMPE criticized was the Physician Quality Reporting System (PQRS), which would increase the number of required measures that CMS would use to allow doctors to earn an incentive and avoid penalties from three to nine. The goal of PQRS is to encourage doctors to report their quality processes. MGMA-ACMPE maintains that such a large increase in the number of required measures is not justified, given the lack of experience many doctors and practices have with the program. The organization's report called on the final version of CMS's rule to include criteria that was more achievable so that doctors could obtain PQRS incentives next year and avoid penalties in 2016. MGMA-ACMPE's report also criticized CMS' Physician Compare Web site, which allows consumers to evaluate and compare doctors and their practices. MGMA-ACMPE said that the Web site can contain inaccurate information that can take months to be corrected. The final version of CMS's rule is scheduled to be released in November. It remains to be seen whether CMS will take into account MGMA-ACMPE's criticism.

Medicine, Drugs and Devices

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The final version of the Food and Drug Administration's unique device identifier (UDI) rule is coming under fire from some who say that it will take too long for the rule to be fully rolled out. The rule, which requires device manufacturers to assign a unique device identifier number to some medical devices but does not mandate compliance by healthcare providers, will initially apply to high-risk devices next September before being fully expanded in 2020. Both the Healthcare Supply Chain Association, which represents group purchasing organizations, and the Premier healthcare alliance have said that the seven-year time frame for rolling out the rule is too long. Meanwhile, some experts say that making the participation of healthcare providers voluntary could it make it difficult to achieve all of the UDI system's possible benefits. According to the FDA, those benefits include a reduction in medical errors, more accurate adverse events reports, and greater knowledge of the underlying problems in medical devices. However, the medical device industry was able to win some changes to the final rule that it had asked for, including the removal of a requirement for device manufacturers to directly mark implantable devices, the addition of a provision that allows companies to apply for an extension, and an exemption for single-use devices. Finally, components of kits will not be required to be individually marked.


Four members of the House of Representatives and five health systems are calling on the Office of Management and Budget (OMB) to finalize its rule for the unique device identification (UDI) system. The rule, which was supposed to be finalized in June, will gradually require medical device manufacturers to mark their products with unique identifiers. The rule is expected to help hospitals track medical devices during product recalls and improve the efficiency of the healthcare supply chain. In a letter to OMB dated Sept. 12, the four House members said that they were disappointed that the Obama administration had missed the deadline for finalizing the rule even though OMB had been reviewing the proposed UDI regulations for roughly a year. The lawmakers also urged OMB to provide a status update on efforts to finalize the rule. The five health systems, meanwhile, also called on OMB to complete its review of the UDI regulations so that hospitals can integrate the UDI system into electronic health records. The health systems also said that the rule should be finalized before electronic health-records standards and policies are updated again.


Researchers in Brazil have performed a study that examined the usefulness of ultrasound in showing subclinical foot disease in rheumatoid arthritis (RA) patients. One hundred patients were recruited for the study, 50 of whom were healthy and 50 who had RA and asymptomatic feet. Researchers examined 22 joints in each individual and compared the two groups of participants bilaterally. They observed significantly higher values in the RA group regarding quantitative synovitis in all joints' recesses, the presence of synovitis--with the exception of the fifth tarsometatarsal and third metatarsophalangeal joint--power Doppler signals, and bone erosion, with the exception of the talocrural and talocalcaneal joints. As a result, researchers concluded that performing an ultrasound on RA asymptomatic feet demonstrated a significantly larger number of inflammatory changes in current activity (synovitis, PD signals) and sequelae (erosion) compared to the control group. The study also concluded that the talonavicular joint in the midfoot has the largest number of ultrasound findings.