News From ACFAS

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To better serve you as an ACFAS member at the local level, the College’s 14 Divisions will be redistricted into nine new Regions to balance them more financially and by membership size. This change, effective January 1, 2018, comes two years after the Division Presidents Council began the process to level the field in terms of local support across all membership areas.

The nine Regions will continue to offer local ACFAS programming, such as:

• student scholarships
• grants for local resident and postgraduate fellow research
• local ACFAS On the Road programs
• resident Complications Courses
• other seminars, local educational offerings and member support

“Through the dedication and collaboration of the Division presidents and ACFAS staff, we were able to complete this task and to help the College enhance its programming and communication with the students, residents and ACFAS members,” says Eric G. Walter, DPM, FACFAS, chair of the Division Presidents Council and member of the ACFAS Board of Directors. “We look forward to offering ACFAS members more focused local support after the new year.”

The ACFAS Region officers are excited to wrap up the redistricting process and to start working in their new geographies. Watch your email for notifications of ACFAS Region programming and plan to attend your new Region’s membership meeting during lunch at the 2018 ACFAS Scientific Conference in Nashville in March. Complications, controversies and challenging cases make for a great learning experience. Faculty will share how they managed their way through difficult clinical scenarios in the new advanced seminar 3 Cs of Deformity Correction, November 4–5 in Scottsdale, Arizona.

Experienced faculty will review complex reconstructive cases to help you:

• Improve your surgical decision-making and problem-solving skills
• Identify and avoid surgical pitfalls at any stage in a case
• Achieve optimal patient outcomes

This seminar is worth 14 continuing education contact hours. Visit acfas.org to register today. The U.S. Centers for Medicare and Medicaid Services (CMS) has withdrawn a proposed rule that would require physicians who furnish and fabricate custom orthotics and prosthetics to achieve additional education and certification to continue to provide these services. ACFAS commented on this proposed rule in March 2017.

Physicians were previously exempt from these requirements. Foot and ankle surgeons already receive education and training that informs the decision-making process in orthotics fabrication, making this rule burdensome. Face your toughest forefoot injury and deformity cases head on when we get “In the Trenches” at the Regional Programs. Register now for one of the upcoming In the Trenches Workshop & Seminars and gain smart solutions you can put to use immediately on Monday morning.

Friday night starts with the presentation, “Controversies and Complications,” followed by Q&A with faculty and your colleagues during which you can share your own work cases. Hear insightful lectures on Saturday then dive right into two sawbones labs on osteotomies and the Big 6 Techniques.

Visit acfas.org/ontheroad for the full On the Road schedule and to register since space is limited. This month, ACFAS would like to know which electronic medical record (EMR) system you use in your practice. Take our new poll at right to let us know, and be sure to check acfas.org for real-time results throughout October.

Foot and Ankle Surgery

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A study was conducted to radiographically clarify the characteristic foot shape in the presence of second metatarsophalangeal (MTP) joint dislocation. Weightbearing foot radiographs of 268 patients with hallux valgus were studied. They were split into two groups: those exhibiting second MTP joint dislocation and a control group that lacked dislocation. Parameters quantified included the hallux valgus angle (HVA), first-second intermetatarsal angle (IMA), second MTP joint angle, hallux interphalangeal angle (IPA), second metatarsal protrusion distance (MPD), metatarsus adductus angle (MAA) and the second metatarsal declination angle (2MDA). In addition, the dislocation group was divided into three subgroups according to second toe deviation direction: medial type (group M), neutral type (group N) and lateral type (group L). The IPA and the 2MDA were determined to be significantly greater in the study group than in the control group. Multiple comparison analysis showed the IMA was greatest in group M and smallest in group L. The IPA was smaller and 2MDA greater in group N than in group L. Finally, the HVA and MAA in group L were greatest, and MPD in group L was smallest.


A study was conducted to demonstrate the use of the periosteal portion of the medial femoral condyle (PMFC) flap for soft-tissue reconstruction of the distal leg, foot and ankle. A single-center, retrospective series of six patients with distal leg, foot and ankle wounds was conducted, with all patients undergoing reconstruction using the PMFC flap. Five of the patients had chronic wounds, and no incidences of flap loss occurred. Five patients healed without complications. Four of them had received immediate skin grafting, while one underwent concomitant skin paddle reconstruction. The last patient needed a second surgery with a rotation flap for recurrent osteomyelitis and wound infection two months following the initial surgery. Average operative time decreased after a two-case learning curve.


A study was conducted to compare postoperative results following total ankle arthroplasty (TAA) at an orthopaedic specialty hospital (OSH) with a matching cohort of patients undergoing TAA at an academic teaching hospital (ATH). The researchers identified all TAA from January 2014 to December 2014 at an OSH and January 2010 to January 2016 at an ATH. Results analyzed included length of stay (LOS), 30-day readmissions, mortality, reoperation and inpatient rehabilitation utilization. Forty TAA patients were included in each cohort. OSH and ATH patients were similar in age, body mass index, age-adjusted Charlson Comorbidity Index and gender. Average LOS for TAA at the OSH was about 1.28 versus about 2.03 at the ATH. No OSH patients were readmitted within 30 days, compared with two ATH patients readmitted. Two OSH patients and two ATH patients needed reoperation. No mortalities occurred in either group, and no OSH patients required transfer. Primary TAA performed at an OSH had substantially shorter LOS in comparison with a matched patient treated at an ATH with no significant difference in readmission or reoperation rates.

Practice Management

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Preparing a practice for potentially disruptive crises is dependent on risk management beforehand. Practice owners should maintain a basic checklist of vital documents they should carry and that are necessary for rebuilding their financial and legal life. Required checklist items include insurance documents, including life, health, disability and loss; an estate plan that includes various powers of attorney; professional licenses; a final copy of their statement from various financial institutions; tax records; anything essential to continuation of their business; and all vital legal documents that are not formally recorded. These documents also need to be consolidated in a secure location that is waterproof and fire-rated and that owners and other trusted associates or family members have access to. Preparedness should include having both a physical back-up of these documents and one available online. It is crucial that others are aware that the physical records and their online back-ups exist and that the right people can access them in the event of the owner's death, injury or other incapacity or unavailability. Finally, practice owners should consider what critical physical items they would have to take with them in such circumstances, including required medication or medical devices for all family members, any cash or other small portable items of value and any items needed for personal security.


Physician burnout is an issue that can cut into quality of care and safety at hospitals. Furthermore, research estimates that half of all U.S. doctors experience burnout. Despite knowledge of the problem, little has been done to address it. Tait Shanafelt, MD, from Stanford University and colleagues researched the topic and determined that research would be more common if hospitals knew of the costs burnout can create. The researchers also determined the level of return on investment when burnout is reduced. They found that physician turnover related to burnout costs $500,000 per doctor. Meanwhile, efforts to reduce burnout can produce dramatic savings. The researchers discovered that organizational interventions were more effective at reducing burnout than physician-level interventions.


To prevent embezzlement at medical practices, it pays to understand an embezzler's profile. Embezzlers are frequently women with no criminal history who have worked their way up through the practice's hierarchy. Motivations for embezzlement can range from financial difficulties to addiction to drugs, gambling or alcohol to a desire to live lavishly. Embezzlement can begin with "borrowing" small amounts of money and escalate from there. Warning signs of possible embezzlement can include employees who become secretive about their work, sudden displays of affluence, frequent requests from employees that physicians sign checks during a busy time of day and indispensable workers who often work late, do not like sharing tasks and refuse to take vacations.

Health Policy and Reimbursement

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Republicans' latest effort to repeal the Affordable Care Act sputtered to an end when Senate GOP leaders scrapped a vote on a bill that had failed to gain sufficient traction within their party. "We haven't given up on changing the American healthcare system," said Sen. Mitch McConnell of Kentucky, the majority leader. "We are not going to be able to do that this week, but it still lies ahead of us, and we haven't given up on that." Democrats responded by calling for the resumption of bipartisan negotiations to stabilize health insurance markets.


Health insurer Anthem says it will no longer allow most patients to get MRIs or CT scans at hospital-owned, outpatient facilities. Instead, the health insurer will require these procedures to be done at independent imaging centers. Anthem says the change will result in improved care and lower costs. Critics say the rule will create fragmented care for patients. The new rule will apply to 4.5 million enrollees in individual and group plans in 13 of the 14 states in which Anthem does business.


A new Reach Health survey determined healthcare executives are increasingly prioritizing telemedicine for delivering care services as the industry migrates to value-based care from fee-for-service. Fifty-one percent of the polled executives and caregivers cited telemedicine as a high priority, 36 percent called it a medium priority and only 13 percent said it is a low priority. A total of 436 executives and caregivers also were asked which telemedicine projects are already highly successful. More than 50 percent ranked improving outcomes, engagement and satisfaction as such, while 26 percent said initiatives to lower costs are highly successful and 18 percent said the same about reducing readmissions. The top five challenges of telehealth for hospitals are Medicare reimbursement, inadequate telemedicine equality laws, Medicaid reimbursement, private payer reimbursement and a shortage of common electronic health records in hub-and-spoke hospitals. Thirty-nine percent of provider organizations said they follow an enterprise approach in which telemedicine initiatives are centrally managed across service lines and settings of care. In addition, 36 percent said they take a departmental approach, where telemedicine initiatives are started and managed by individual departments. Another 25 percent noted they began with a departmental approach and are transitioning to an enterprise model.

Medicine, Drugs and Devices

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Researchers at the University of Missouri School of Medicine believe biologic joint restoration using donor tissue may be a viable option for active patients with joint defects. The researchers discovered that treating donor grafts with bone marrow aspirate concentrate (BMC) resulted in improved bone integration and speedier recovery times. The researchers' study found that grafts pretreated with BMC had 43 percent bone integration after six weeks. After three months, pretreated grafts achieved 67 percent integration, and after six months, that percentage increased to 84 percent. James Cook, DVM, PhD, OTSC, the William and Kathryn Allen Distinguished Chair in Orthopaedic Surgery at the MU School of Medicine, says, "Our data shows that donor grafts pretreated with BMC were associated with earlier and better bone integration. This means that pretreatment with BMC reduces the risk of bone graft failure and improves patients’ chances for long-term success."


Moody's Investors Service says in a report that inpatient drug costs will continue to increase for nonprofit hospitals, but the pace of those increases will slow as criticism grows concerning rising medicine prices. Diana Lee, a Moody's vice president, added that some relief will also come from the U.S. Food and Drug Administration approving more generic drugs for the first time.


A seven-year review of U.S. Food and Drug Administration (FDA) inspections of medical device manufacturing facilities and subsequent recalls at such plants published in Manufacturing & Service Operations Management found rotating plant inspectors more often could reduce the likelihood of recalls. The researchers assessed the predictive relationship between 4,767 FDA plant inspection outcomes and 2,863 medical device recalls stemming from 2,244 plants from 2000 to 2006. Such FDA inspections typically occur every two years. The team calculated a 21 percent elevation in the risk of a future recall the second time a FDA investigator inspected a plant, which rose to 57 percent by the third visit. These findings were irrespective of whatever score the FDA investigator gave the facility. In comparison to a low-quality inspection outcome, the researchers determined a high-quality inspection outcome from an investigator who has never inspected a plant before anticipated a 31 percent reduced risk of a recall from that plant. The team says a rotation strategy could lead to about 100 fewer costly medical device recalls annually, or about 20 percent fewer recalls, in exchange for an increase of $800,000 in additional travel expenses for FDA.