News From ACFAS

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Starting next week, voting for the 2013-2014 ACFAS Board of Directors will begin. After careful review and consideration, the Nominating Committee has recommended the following Fellows for the upcoming electronic election to determine who will serve on the ACFAS Board of Directors:

• Sean T. Grambart, DPM, FACFAS (Incumbent)
• Paul Dayton, DPM, FACFAS
• Christopher L. Reeves, DPM, FACFAS

Two, three-year terms will be filled by election. Candidate profiles and position statements are currently posted on acfas.org/nominations. Voters may cast one or two votes on their ballot. Regular member classes eligible to vote are: Fellows, Associates, Emeritus (formerly Senior) and Life Members.

ACFAS will use electronic voting again this year from November 29-December 29. All eligible voters will receive an e-mail with special ID information and a link to the election website no later than November 29. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot, pursuant to the bylaws. Eligible voters without an e-mail address will receive paper instructions on how to log in to the election website and vote. There will be no paper ballots. Do you have a desire to get involved with ACFAS, and give back to your local foot and ankle surgical community? Now’s your chance! Four of the ACFAS Regional Divisions currently have openings in their officer slates, and are holding open calls for volunteers. Click on the Division you reside in to see details about the available volunteer position:

• Division 1 “Pacific”: ACFAS Division 1 covers the states of California and Hawaii, and Guam. They are seeking a Secretary.
• Division 5 “Florida”: ACFAS Division 5 members reside in the state of Florida. The Division is in need of a new Secretary/Treasurer.
• Division 6 “Midwest”: ACFAS Division 6 encompasses the Midwest states of Illinois, Iowa, Kansas, Minnesota, Missouri, Nebraska, North Dakota, South Dakota and Wisconsin. The Division needs a new Secretary.
• Division 10 “Upstate New York”: ACFAS Division 10 encompasses the upstate portion of New York State, outside of New York City and the surrounding areas. They are in need of a new Vice President.

The above Divisions will hold an election of all submitted names in January, and the positions will begin their terms in time for the 2013 Annual Scientific Conference, February 11-14, in Las Vegas. Terms are three years in length, and most Divisions provide the opportunity for officers to succeed up to other positions in the officer slate.

Do you live in one of the above Divisions and are interested in learning more, or are you interested in submitting your name to be considered for one of the above positions? Contact the College at membership@acfas.org, or watch your email for your Division’s “Call for Volunteers” communications, which will be sent out in the next week. The tendon is never what it seems. Register for the ACFAS 2013 Pre-Conference Seminar: Advanced Tendon Repair and Fixation. This course is worth eight continuing education contact hours and will supply you with contemporary, distinct knowledge on how to more effectively evaluate, manage and reconstruct tendon ruptures and injuries; gain a better understanding of tendon to bone fixation and indications for use; and you’ll get some experience in the execution of tendon transfer for common and complex deformities.

You are sure to learn something new at this ACFAS 2013 Pre-Conference Seminar, Sunday, February 10 from 7am-4:30pm in Las Vegas. Check out the Advanced Tendon Repair and Fixation seminar webpage for information on fees and everything included with your registration. Register now if you’d like to attend, as this class is limited in size.

Foot and Ankle Surgery

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A study was performed to ascertain the clinical and functional results of high-grade open calcaneus fractures treated with modern wound care, open reduction via the medial hindfoot injury and percutaneous screw fixation. The study involved a single surgeon treating 17 consecutive patients with open type II and III calcaneus fractures using fracture repair. Fifteen of the patients completed all outcome measures. Four fractures were graded as type II, nine were graded as type IIIA and four were graded as type IIIB. One deep infection and one wound dehiscence occurred in type III open injuries that were successfully treated with local wound care, delayed closure and suitable antibiotics. Secondary surgical procedures were needed for seven of the 17 patients, including four hindfoot fusions. The median AOFAS score was 77 while the Maryland Foot Score was 64. The physical and mental elements of the Short Form 36 respectively averaged 44.4 and 49.1.


A biomechanical comparison of the ultimate load to failure and stiffness of the traditional Brostrom method for repairing chronic lateral ankle instability using only suture fixation versus a suture anchor repair of the anterior talofibular ligament (ATFL) at time zero was performed. The purpose of the comparison was to test the hypothesis that fixation strength of the suture anchor repair would be nearer to the strength of the native ligament and permit more aggressive rehabilitation. The study involved 24 fresh-frozen cadaveric ankles randomly split into four groups of six specimens. One group served as an intact control group, while the others comprised the traditional Brostrom and two suture anchor modifications of the Brostrom procedure. Load-to-failure testing demonstrated that both ultimate failure loads and stiffness of the Brostrom, suture anchor fibula and suture anchor talus repairs were substantially lower than that of the intact ATFL group. The three repair groups did not significantly differ, but all of them were significantly lower in strength and stiffness in comparison to the intact ATFL.


Distal tibial hypertrophic nonunion with angular deformity has been successfully treated by a circular external fixator, but the inconvenience of the bulky external fixator and frequent pin tract infection makes the method unappealing in many cases. A new study, including thirteen patients with angular deformity of the distal dia-/metaphyseal tibial shaft, tested the efficacy of an alternative treatment. Five patients were originally treated by interlocking nail, three were treated by plate and screws fixation, four treated conservatively, and one had deformity secondary to fracture of a lengthening regenerate. All patients were treated by osteotomy and acute correction of the deformity using temporary unilateral fixator and internal fixation by a locking compression plate (LCP). The external fixator was removed at the end of surgery, and the results were evaluated both clinically and radiologically. All osteotomies healed within three months, and all patients were able to work within an average of 2.3 months. The function of the upper ankle joint was unrestricted in twelve cases, with a mild functional deficit in one case. The mean follow-up was 60 months; and the frontal plane alignment parameters and the sagittal alignment parameters were within normal values postoperatively. No cases of deep infection or failure of fixation were encountered. Ultimately, the study showed that acute correction of distal tibial shaft hypertrophic nonunion with deformity and LCP fixation is a reliable option in well-selected cases.


Introducing the experience of treating calcaneal fracture malunion was the purpose of a study involving 11 male patients treated operatively between December 2009 and April 2011, with an average follow-up of 13.5 months. Eight of the patients were right-sided and the remaining three were left-sided, while the cause of the fractures was a fall from a height. All of the patients were treated non-operatively since the prime injury, and the extended lateral calcaneal "L" approach was applied in all cases. Lateral wall exostectomy and peroneal tendons were decompressed beneath the tip of the lateral malleolus and in situ subtalar bone block arthrodesis was performed. The average AOFAS and pain score systems score rose from 33 preoperatively to 69 postoperatively, and reported complications were superficial wound infection in two instances and reflex sympathetic dystrophy in three instances.

Practice Management

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A study was held to identify the impact of health belief model factors on daily foot-exam practice among 277 diabetes mellitus patients with peripheral neuropathy. Family support and health belief factors were respectively quantified with the Family APGAR and Diabetic Foot Ulcer Health Belief Scale. Structured questionnaires were used to gather data on foot-exam practice, perceived self-efficacy and action cues, while the data was analyzed through logistic regression. Regression demonstrated that select action cues—namely recommendations from family, friends or health professionals—perceived self-efficacy and perceived barriers had an interactive influence on participants' daily foot-exam practice.


Practices are urged to consider the patient experience holistically when it comes to maintaining patient satisfaction and ensuring that a visit is as pleasant as possible. For instance, a PwC poll of 6,000 people issued July 26 found that 34 percent of respondents were willing to change physicians if offered an ideal experience elsewhere. Practices must devote attention to patients' experiences if they wish to improve their customer service, and a consultant notes that correcting patient experience problems is often not insurmountable. Weighing the experience of making an appointment is the first step, with consideration given to the number of phone rings before the patient's call is picked up, and the amount of time patients spend on hold. Staggering schedules so the phone is almost always answered by a staffer, especially during the lunch hour, can lower patient frustration.

Consideration of the waiting area is the next step, as practices should guarantee that the waiting experience is pleasant. Recent magazine issues should be available, while some practices may consider offering refreshments when a patient comes in. Patients should be informed of any delays and provided estimates as to when they will be seen. A consultant says this is all part of cultivating a positive relationship with the patient so that they will return for subsequent visits and recommend the practice to others. Attention should next be focused on the exam room experience, with one consultant noting that patients should have something to do to keep them occupied while waiting for the physician, especially if there is a delay.

When physicians arrive for their visits, knowing the patient's history and respectfully listening and talking to the patient can show the patient that they care. Consultants recommend that physicians review a patient's chart prior to entering the exam room, and sit in front of the patient and make eye contact when in the exam room. A patient's exit of a practice following the completion of services can be just as critical as how they enter, according to practice consultants. Patients ought to be told when the visit is over and what they should do next by the physician or another staffer, while well-placed signs can direct them to checkout.


The number of physicians who practice independently, rather than employed by medical groups or systems, will decline from 57 percent 12 years ago to 36 percent by next year, according to a new study by Accenture. The report also projects that one-third of physicians who stay in private practice may opt for a subscription-based model over the more traditional model. Such a model can include the patient paying regular set fees, and the physician limiting his capacity to a certain number of patients so that he or she can spend more time with each one and concentrate on prevention and treatment of chronic diseases.

The Accenture study is based on a poll of 204 physicians, and the researchers learned that physicians are more and more open to new business models, particularly those that could potentially limit paperwork demands and overhead costs. Subscription models run the gamut from concierge practices that may charge up to $30,000 annually for a personal, readily available physician, to direct-pay models where the costs to patients are considerably less. In return, patients can access things such as same-day appointments, online prescriptions and email communication with providers.

Accenture Health Managing Director Kaveh Safavi says physicians' migration to subscription-based models is being driven by factors that include the desire to remain independent, and the push to grow their salary. "Basically they're saying, 'Why don't we provide a higher level of service and still have a strong economic position,'" he notes. Among physicians' biggest concerns are business costs, managed care and electronic medical records, while physicians also aim to control the number of patients they see every day, since the models charge regular set fees to compensate for a lower volume of patient visits. According to Safavi, the subscription model is targeted toward higher paying clients, and delivering more convenient, streamlined healthcare in exchange for the higher cost. However, he thinks the model will have little impact on patients who depend on their insurance plans or on programs such as Medicare and Medicaid.


St. John's Hospital and Memorial Medical Center in Springfield, Ill., have initiated telemedicine programs to deliver faster specialty care for patients in rural hospitals across central and southern Illinois. St. John's has deployed telemedicine equipment at Hillsboro Area Hospital in Springfield, St. Francis Hospital in Litchfield and Boyd Memorial Hospital in Carrollton, while Memorial has launched a telemedicine partnership with Abraham Lincoln Memorial in Lincoln and is striving to make similar services available to Sarah Culbertson Memorial Hospital in Rushville. The hospitals are initially concentrating on early detection and treatment of strokes and other neurological problems in adults, with plans to eventually serve patients with other conditions. St. John's hopes to start offering pediatric telemedicine services by spring and broaden the reach of Springfield-based specialists to patients in rural intensive-care units. The first phase of telemedicine involves SIU neurologists using webcam-equipped computers that link them with telemedicine "robots" at the rural facilities. The robots employ HD video technology to let physicians and patients see each other, engage in conversations and even see scans and other test results. The robots feature stethoscopes so the physician on the other end can hear the patient's heartbeat with the assistance of a nurse or physician who holds the scope over the patient's chest.

Health Policy and Reimbursement

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The Obama administration filled in key details on how the health reform law will regulate insurance plans by issuing two long-awaited regulations on Tuesday. One proposed rule on health insurance market reforms spells out how the health law's "guaranteed issue" and "community rating" requirements will work in practice. A second rule underscores the law's requirement that all insurance products sold in state individual and small-group markets include a list of "essential health benefits." A third proposed rule provides guidance for employers that offer their workers wellness programs.


Physician review websites could potentially pose legal challenges, especially if a physician given a negative profile on such a site counters aggressively. The case of a Minnesota neurologist who is suing a patient's family for defamation after the patient posted negative online reviews could set a precedent for future legal proceedings, according to lawyers for both sides. "You can exacerbate the situation if you respond too combatively—and that can lead to more negative comments," warns Reputation.com Vice President Brent Franson. He notes that privacy issues also can crop up when physicians make an online response to a website's review, and his advice is to be "very polite and specific" when doing so. Franson also suggests that physicians run Google searches on themselves. If they do not like the results, it is not unreasonable to ask patients with whom they have friendly relationships to post reviews that may offset negative comments, provided they are not offered financial compensation and a positive rating is not specifically requested. "You want to ask for 'honest feedback'—and you don't want to incentivize feedback," Franson says. Despite the general perception that physicians are discomforted by the idea of online ratings, most physician reviews are positive, according to a study published earlier this year by the Journal of Medical Internet Research. Consultant Kenneth Hertz recommends that physicians accept the reality of social media. "You have to be doing your best all the time to provide remarkable service to people, because—if they don't like it—it's out there in a minute," he observes.


The Department of Health and Human Services is holding from now until Jan. 7, 2013, a public comment period on the proposed methodology to determine what precisely defines a Frontier and Remote (FAR) area. The methodology that is ultimately adopted will be used as the basis for suitable levels of federal funding and grants for rural healthcare providers. "We highly encourage anybody who could be impacted or who is considered remote or frontier to look closely at this definition and ask questions and provide content," says National Center for Frontier Communities Director Susan Wilger. Among the issues rural healthcare proponents have with the methodology is whether it is consistent with existing definitions to frontier. Other questions Wilger cites include the methodology's foundation on 2000 rather than 2010 census data, and the lack of incorporation of all 50 states. The prevalence of questions about the proposed FAR definition gives solid reason for rural providers to defend their territory, Wilger says. "We don't want to water down the few resources that are available to rural, frontier and very remote healthcare service providers," she notes. "They are already dealing with really sparse resources and unique challenges."


Doctors who were unable to meet Medicare electronic prescribing requirements will have a second chance to claim a hardship exemption and prevent the 2013 e-prescribing penalty from reducing their Medicare pay. The Centers for Medicare & Medicaid Services (CMS) will allow physicians and other eligible health professionals an additional window of time in which to file hardship exemptions, indicating to the agency that a 1.5 percent penalty should not be applied to all Medicare rates next year, officials said. Any physician who did not request an exemption by the original due date now can file a hardship application by Jan. 31, 2013. CMS is required by law to reduce Medicare rates for eligible professionals who do not meet e-prescribing reporting requirements.

In mid-October, CMS officials sent email notices announcing the re-opening of the 2013 hardship exemption application Web portal starting on Nov. 1. The exemption categories are available only to physicians and health professionals who could not e-prescribe due to state, federal or local law or regulation; lacked sufficient e-prescribing opportunities, such as by ordering fewer than 100 prescriptions during the six-month reporting period; practiced in a rural area without sufficient high-speed Internet access; and practiced in an area without sufficient numbers of pharmacies that can accept paperless medication orders. The proposed schedule would create two additional e-prescribing exemption categories for doctors who earn, or who plan to earn, EHR bonuses. Those additional exemptions would not be available to doctors until after CMS confirms them in the final fee schedule.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration (FDA) wants to broaden its authority over compounding pharmacies, especially in view of one such pharmacy's role in a multistate meningitis outbreak traced to contaminated steroid injections. The agency is being scrutinized for its oversight of the New England Compounding Center (NECC) in Massachusetts, deemed to be responsible for distributing tainted vials of methylprednisolone acetate. In the wake of the outbreak, NECC and Ameridose, a supplier of sterile admixing and repackaging services, have ceased operations. Furthermore, both companies have recalled all products distributed this year. Current statutes stipulate that the FDA has oversight for drug manufacturing, while state boards of pharmacy oversee compounding pharmacies, which are expected to produce medications for a specific patient. The House Committee on Energy and Commerce Subcommittee on Oversight and Investigations and the Senate Committee on Health, Education, Labor and Pensions are expected to hold independent hearings concerning the meningitis outbreak, and FDA officials are expected to deliver testimony at both hearings. Lawmakers have urged legislation that would widen oversight of compounding pharmacies.


Electronic prescribing is rapidly expanding in part due to Medicare penalties for not implementing it. At the end of 2011, 58 percent of office-based prescribers sent 36 percent of all prescriptions electronically to pharmacies and mail-order houses, and 91 percent of community pharmacies were able to receive online prescriptions. But practices still experience some problems with e-prescribing, such as inadequate integration within staff members' routines.

Rosemarie Nelson, a principal of MGMA Health Care Consulting Group, says this could lead to staff failing to enter medication lists for patients who have not been seen since the doctor started e-prescribing, or not asking patients about their preferred pharmacies. Meanwhile, doctors who use standalone e-prescribing software and do not have an interface with the practice management system will need to enter such information manually.

Surescripts, a national clinical e-prescribing network, notes that Electronic Prescriptions for Controlled Substances (EPCS) is illegal or has an undetermined legal status in about a dozen states. Even in states that allow EPCS, Surescripts requires software vendors to get certification for EPCS before prescribers can use their programs for that purpose. Prescribers must also get an audit report from the vendor and must submit to "2-factor authentication" before digitally signing an electronic prescription for a controlled substance.

Electronic renewals can be problematic when physician offices or pharmacies do not communicate adequately, or practices have not set up a workflow for renewals. Meanwhile, many e-prescribing systems lack drug-allergy and drug-condition alerts, according to a study from the Center for Studying Health System Change.