News From ACFAS

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Don’t miss your chance to save $75 or more on registration for ACFAS 2015 in Phoenix! The last day to register at the Early Bird rate is Friday, December 5.

Visit acfas.org/phoenix to register, book your hotel reservation and learn more about all that awaits you in Phoenix. From expert speakers to hands-on clinical, surgical and practice management sessions to unlimited networking opportunities, it’s no wonder the Annual Scientific Conference is considered the premier educational event for foot and ankle surgeons nationwide. This Friday, ACFAS voting members (Fellow, Associate, Life and Emeritus members) will receive an email from the College’s independent election firm with their unique link to the 2015 Board of Directors Election website. The email will come from acfas.ballot@intelliscaninc.net. If you do not have a valid email address on file with the College, you will receive voting instructions via US mail.

Please watch for this email and cast your vote for your elected leadership. Candidate information can be viewed now at acfas.org/nominations. Make sure your voice is heard as your vote is important to advancing our profession and surgical specialty. In an effort to support the next generation of researchers, the ACFAS Regional Divisions are offering monetary assistance to resident poster and manuscript presenters attending ACFAS 2015. If you are a resident member who has submitted a poster or manuscript accepted for presentation at the conference, and you are interested in receiving funding from your local Division, submit an application to your Division’s President (names and email addresses are available on the Divisions’ webpages at acfas.org). Each Division will determine the amount of support they can provide based on the number of submissions received and will contact you directly with next steps.

For a complete listing of the standardized process for residents throughout the country to have access to ACFAS Division funding, visit acfas.org. Promoting your practice has never been easier with the Winter edition of FootNotes. Visit the ACFAS Marketing Toolbox at acfas.org/marketing to download this latest issue, which includes the following articles:

• Protect Your Feet and Ankles from Winter Weather
• “But I Can Still Walk on It…” Debunking Broken Toe Myths
• Getting Fit in the New Year

Each issue of FootNotes can be customized with your office’s contact information to help grow your practice and attract new patients. Don't forget to also put copies of FootNotes in your waiting room, distribute them at health fairs and speaking engagements or post the articles on your social media sites or company website.

As a member, you can also take advantage of the many other free ready-to-use resources available in the ACFAS Marketing Toolbox, including PowerPoint presentations, press release templates and other tools, all designed to help your practice thrive in the new year. Looking for a new practitioner for your practice? Employers can take advantage of the new ACFAS Job Fair at the Annual Scientific Conference in Phoenix by posting open positions on bulletin boards at the fair and also online via the PodiatryCareers.org career center. The PodiatryCareers.org online tool also allows employers and potential employees to connect and potentially meet for interviews during the conference.

Plan ahead and consider posting your open position at the ACFAS Job Fair—more details will be made available soon at acfas.org. ACFAS' Annual Scientific Conference attracts the best and brightest speakers and attendees—use the job fair to attract them to your practice, as well!

Foot and Ankle Surgery

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A study was held to assess the effectiveness of an imaging protocol involving radiographs, computed tomography (CT) and magnetic resonance imaging (MRI) in a distal one-third spiral tibia fracture cohort. The study involved administering a standardized ankle imaging protocol to all operatively treated patients with a spiral distal one-third tibial shaft fracture from February 2012 to March 2013. Patients received preoperative orthogonal ankle radiographs and a CT scan of the tibia that included the ankle. All ankle imaging was studied for proof of an ankle injury, and if no ankle fracture was identified, patients received an MRI. Twenty-five patients satisfied the inclusion and exclusion criteria for this study. Concomitant osseous ankle injuries were identified by radiograph and CT in 56 percent of cases, while 44 percent of patients exhibited no evidence of a combined injury by radiograph or CT and thus underwent an MRI. Sixty-four percent of the MRI cohort had an occult ankle fracture. The overall incidence of a combined injury using the new protocol was 84 percent, and recognition of an occult injury spurred a change in management for all of these patients.


A study was held to evaluate immediate ankle arthrodesis as an approach to expedite recovery in patients suffering from severely comminuted tibial pilon fractures. The researchers conducted open fracture reduction and internal fixation in patients over a two-year period, and 11 patients with severely comminuted high-energy tibial pilon fractures were retrospectively reviewed following surgery with primary ankle arthrodesis and fracture reduction. Anatomically designed anterior ankle arthrodesis plates were used in 10 ankles, while ring external fixation was used in nine ankles with concomitant tibia fracture or in cases requiring extra fixation. Clinical assessment included chart review, interview, the American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score and radiographic evaluation. All ankle arthrodeses healed at an average of 4.4 months. One patient exhibited a nonunion at the metaphyseal fracture, which healed with revision surgery. The average AOFAS ankle-hindfoot score was 83, with 88 percent having a good or excellent outcome. Radiographic and clinical analysis verified a plantigrade foot without malalignment, and no patients needed revision surgery for malunion.

Practice Management

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A bill introduced by Senators Michael Bennett, D-Colo., and Orrin Hatch, R-Utah, would exempt regulation of electronic patient records and certain kinds of decision support software. The Medical Electronic Data Technology Enhancement for Consumers’ Health (MEDTECH) Act would exempt software intended only for administrative or operational support and software and health IT products intended for use in activities unrelated to clinical treatment. The exemption would apply to software intended for handling clinical laboratory test report data before analysis as well as software used to analyze and support the display or printing of patient or other medical information for providing prevention, diagnostic or treatment recommendations. Electronic patient records that functionally represent a medical chart and are created, stored, transferred or reviewed by healthcare professionals or others working under the supervision of such professionals will be exempt as well. Such records do not include diagnostic image data. Bradley Merrill Thompson, general counsel for the Clinical Decision Support (CDS) Coalition, says the MEDTECH Act takes a straightforward approach to identifying several categories of low risk technology that should not be regulated. "If the software is simply doing what software does best, which is retrieving data and doing calculations, but the user has all of the information at his or her fingertips, the decision-making of the user is really governed under the practice of medicine and is not something into which FDA should intrude," says Thompson.


The proliferation of high-deductible health plans has resulted in patients bearing higher out-of-pocket expenses than they had in the past, which in turn has resulted in more delinquencies and a greater use of collection agencies by physicians' practices. However, collection agencies should be a last resort when collecting past-due balances because of the high fees these agencies charge. Instead of reflexively turning to collection agencies when a patient's account is in arrears, a physician's practice should first complete its internal process for collecting on past-due balances. Such a process should include several elements, such as flagging charts of patients with past-due balances and being prepared to address the issue with the patient the next time he or she comes for an appointment, training designated staffers to have financial conversations with patients in appropriate locations in the office and sending statements to patients as soon as their financial responsibility has been determined. If a patient does not respond to two statements, the practice should turn to a third party who will write, sign and send out pre-collection letters on practice letterhead. A third party is generally a better choice than internal staff for sending out pre-collection letters because practice employees generally view sending out these letters as a lower priority than other tasks. Physicians' practices will likely be more successful at collecting past-due balances by sending out a series of collection letters instead of dunning messages and phone calls, both of which tend to be ignored.

Health Policy and Reimbursement

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The U.S. Health and Human Services Administration should investigate whether hospitals are properly reporting revenue from group purchasing organizations (GPOs), according to a new report from the Government Accountability Office. The report, which voices concerns that Medicare payments are being affected has drawn criticism from some in the medical community. Physicians Against Drug Shortages says it fails to address the role of anti-competitive GPOs in causing drug shortages. GPOs say they are working on the shortage problem, which is caused by manufacturing issues and other factors. According to the Healthcare Supply Chain Association, the report shows that most hospitals are reporting appropriately and transparently.


Incoming Senate Majority Leader Mitch McConnell (R-Ky.) suggested Dec. 2 that the legal challenge to the Affordable Care Act's subsidies could result in the entire law being scrapped, something congressional Republicans have tried and failed to do for the past four years. At issue in the case, which will be decided by the U.S. Supreme Court sometime before next June, is whether subsidies can be provided to consumers who purchase coverage through the federal exchange. Opponents of the Affordable Care Act, McConnell included, are hoping the High Court will strictly interpret a provision of the law that says subsidies can only be given to consumers who purchase coverage from exchanges established by "the state." The law's opponents say that means subsidies can only be given to consumers who purchase coverage through state-run exchanges and that they are not available to users of the federal exchange. But some legal observers disagree, saying that reading the provision in context shows that Congress clearly intended to provide subsidies to users of both the federal and state exchanges. McConnell says a ruling in favor of the Affordable Care Act's opponents would give Congress a chance to replace the law.


A coalition of healthcare professional organizations calling themselves the Coalition for ICD-10 have sent a letter to congressional leaders urging them to forgo any future delays to the current ICD-10 implementation deadline of Oct. 1, 2015. The coalition's members include the College of Healthcare Information Management Executives, the American Health Information Management Association, the Healthcare Financial Management Association, America's Health Insurance Plans and others. They sent their letter to House Speaker John Boehner, Minority Leader Nancy Pelosi and Senate Minority and Majority leaders Harry Reid and Mitch McConnell. In their letter, the coalition says that previous delays of ICD-10 implementation have been "disruptive and costly." They say that delays hinder "healthcare innovation, payment reform, public health and healthcare spending." The coalition notes that nearly three-quarters of U.S. hospitals and health systems actually reported being confident in their ability to successfully implement ICD-10 before the latest delay. Delaying implementation, the coalition argues, creates additional costs by requiring retraining of personnel and reconfiguration of health systems. They also point out the many benefits of ICD-10, including better population health management through tracking and surveillance of pandemics like Ebola.


The National Association of State Budget Officers released a report on Nov. 20 that indicated states are receiving and spending more money on Medicaid thanks to the Affordable Care Act. The report noted that the federal government gave states $41.8 billion more for Medicaid in fiscal 2014, and that this increase was largely due to the Affordable Care Act's expansion of the program. That expansion has been carried out in most states. Under the Affordable Care Act, states are reimbursed 90 to 100 percent for the growing number of Medicaid enrollees allowed for under the healthcare reform law.

Medicine, Drugs and Devices

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A study was performed to determine the interest and attitudes toward lower limb allotransplantation among lower extremity amputees, and an online survey designed in conjunction with and circulated by the Amputee Coalition to lower limb amputees in the United States was used to gain such insights. Seven hundred seventy respondents completed the survey. Forty-three percent of respondents expressed interest in being evaluated for lower limb transplantation, 36 percent declined and 21 percent felt uncertain. Those respondents with an interest in allotransplantation tended to skew younger and were better educated, more recently amputated and less happy with prosthetic outcomes than those who were not interested. The key criterion for transplantation to be considered a success by respondents was restoration of meaningful knee/ankle joint function, followed by restoration of limb sensibility. If immunosuppression was unnecessary, 32 percent of those who initially declined and 88 percent of those who were uncertain would opt for assessment for lower limb allotransplantation.


A study was conducted to assess the midterm outcomes of a new isolated talonavicular (TN) method that applies the principles of static tension banding to the treatment of advanced Müller-Weiss syndrome (MWS). Clinical and radiographic results were examined from a preliminary series of advanced MWS patients treated with the technique. Ten feet in 10 patients with advanced MWS deformity were treated with isolated TN arthrodesis using the tension band technique. American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot score was used to evaluate the functional outcome, and standard angles were quantified to ascertain the amount of correction achieved through the surgery with minimum follow-up at 24 months. Trabeculation was observed crossing the fusion site on radiographs in eight patients after two months and in one patient after three months. One patient required revision surgery after 13 months because of implant failure, and bony healing was achieved two months later following additional screw fixation. At the latest follow-up, all patients described a high level of satisfaction. Postoperatively, AOFAS score rose from 33 to 88.3 points, the anteroposterior talocalcaneal angle increased from 14.2 degrees to 22.7 degrees and the calcaneal pitch increased from 10.3 degrees to 14.7 degrees.