News From ACFAS

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Profiles and position statements of the five candidates nominated for the ACFAS Board of Directors are now posted at acfas.org/nominations. Voting opens December 13 and each eligible voting member will receive an email with their unique link to the election website. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot. Eligible voters without a valid e-mail address will receive instructions on how to log into the election website and vote by U.S. mail. There will be no paper ballots.

Two, three-year terms and one, two-year term will be filled by election. The ballot appearance is prescribed in the bylaws. Eligible voters may cast one, two, or three votes on their ballot. Regular member classes eligible to vote are: Fellows, Associates, Emeritus (formerly Senior) and Life Members. To help establish hospital privileging guidelines for Total Ankle Replacement Surgery (TAR), ACFAS recently released new privileging guidelines for performing TAR surgery. Developed initially by the Professional Relations Committee and refined by a Board of Directors appointed task force, the document provides general guidelines and criteria to both board-certified and board-qualified members seeking privileges to perform TAR surgery.

According to Keith Cook, DPM, FACFAS, and Chairperson for the ACFAS Professional Relations Committee, these new guidelines show ACFAS has taken a major step in assuring that only the most highly qualified, skilled and trained foot and ankle surgeons perform total ankle replacement surgery.

The full guideline document, as well as other position statements are available in the Health Policy and Advocacy section of acfas.org. In an effort to better support resident poster and manuscript presenters in their attendance at the Annual Scientific Conference, the ACFAS Regional Divisions have created a standardized process for residents throughout the country to have access to funding from their local ACFAS Division.

Some of the rules created are:

• Support will be equal for all Divisions: poster submitters are eligible for $250; and manuscript presenters are eligible for $500. The actual number of awards provided may vary by Division, year to year, and will be determined on an annual basis.
• All interested residents should complete an application to be considered for support.
• Posters must be submitted to the College digitally (to be posted on the Division's website in advance of the conference) in order for funding to be provided.
• If your poster is accepted for funding, you are expected to attend the Annual Scientific Conference as well as the Division Membership Meeting at the conference.

If you a resident member who has submitted a poster or manuscript that is accepted for presentation at the Conference, and you are interested in receiving funding from your local Division, you can view the complete rules and the application at acfas.org.

Please submit the form 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.

The ACFAS Regional Divisions are happy to be able to support the next generation of researchers in their parts of the country.

Maximize your knowledge of the latest research in a minimum amount of time through ACFAS' Scientific Literature Reviews (SLRs). The December 2013 edition is complete with reviews prepared by residents at Hunt Regional Medical Center and features articles from podiatry-relevant journals you may not regularly read, including:

• Madura Foot
• Plantarfascia Anatomy and Its Relationship with Achilles Tendon and Paratenon
• Metanx In Type 2 Diabetes with Peripheral Neuropathy: A Randomized Trial

Missed past monthly listings of the SLRs? Find a full library of archived SLRs at acfas.org.

Foot and Ankle Surgery

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Researchers in Finland recently performed a study to identify the most common types of surgical errors that resulted in patients having to undergo early re-operation following ankle fracture surgery. The study consisted of a review of the charts of 5,123 consecutive ankle fracture operations in 5,071 patients, 79 of whom underwent second operations after malreductions were detected. These patients were compared with 79 age- and sex-matched controls who did not require additional surgery. The study found that 59 percent of the 79 patients who needed additional surgery experienced syndesmotic malreduction, making it the most common indication for re-operation. Researchers found that the most common error related to syndesmotic reduction or fixation was fibular malpositioning within the tibiofibular incisura. Other indications for reoperation were fibular shortening, fracture disclocation, and fracture type. Finally, researchers found that malreductions were successfully corrected in 84 percent of cases requiring additional surgery. These corrections were successfully completed in the acute setting, researchers found.


Metatarsal artery perforator (MAP)-based propeller flaps are a good choice for reconstructing distal foot soft-tissue defects, since they provide sufficient skin territory and excellent esthetic and functional recovery, a new study has found. The surgeons who performed the study examined six patients who underwent distal foot reconstruction with seven MAP-based propeller flaps. Five of those flaps were based on the third metatarsal artery, while the other two were based on the first metatarsal artery. The flaps that were used ranged in size from four by two centimeters to eight by four centimeters. Surgeons found that all of the flaps completely survived and that there were no donor site complications. In addition, all patients were walking with no problems within the first month after surgery. The transient distal venous congestion that was seen in two patients subsided on its own without any complications.

Practice Management

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Doctors who are considering terminating a relationship with a troublesome patient should take a number of steps before doing so in order to ensure the patient in question is protected and any legal or ethical problems are avoided. Physicians should keep in mind that the American Medical Association's Code of Medical Ethics obliges them to support continuity of care for their patients. As a result, doctors need to provide the patient and/or relatives and responsible friends at least 30 days warning that they will no longer provide care after a specific date so that the patient can obtain treatment from another caregiver. This warning should be included in a formal discharge letter that should also describe the patient's medical problems and provide contact information for another doctor or a physician referral service. Care should not be terminated if doctors have reason to believe that no nearby providers can provide similar care or services. Doctors should also be sure to document the reasons why care is being terminated so the patient cannot claim discrimination or a violation of the Americans with Disabilities Act. Finally, doctors should protect their practices by going out of their way to ensure that the patient will continue to receive care from someone else so the patient does not post a negative review of the practice online.


A study published in the Journal of General Internal Medicine has found that giving doctors information about the cost of diagnostic lab tests can help them reduce the number of tests they order. Researchers surveyed 215 doctors at Atrius Health, which performed the study, and divided them into two groups: an intervention group that was given real-time information on lab costs for 27 individual tests when they placed their orders for these tests, and a control group that did not receive such information. Utilization rates for all 27 tests declined in the intervention group, though the declines were statistically significant for only five types of tests. The study found that the lower number of orders for these five tests resulted in savings of as much as $107 per 1,000 visits per month. In addition, the study found that 49 percent of doctors believed they had a sufficient amount of information when ordering lab tests. The study concluded that doctors are willing to take steps to control costs within their practices but that they need to be given tools, including electronic health record systems that provide them with cost information, to help them accomplish that goal.

Health Policy and Reimbursement

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The final version of the Medicare physician fee schedule for calendar year (CY) 2014 bases payment rates for physician services on a $27.2006 conversion factor, which is 20.1 percent less than the conversion factor used last year. The conversion factor for CY 2014 will remain in place barring intervention by Congress. The final version of the fee schedule also calls for the physician value-based payment modifier to continue to be implemented by applying the 2016 modifier to groups of 10 or more eligible professionals. Changes were also made to the criteria for earning a bonus and avoiding penalties under the Physician Quality Reporting System (PQRS). In addition, bonuses will no longer be available under PQRS after 2014. Another feature of the final fee schedule is that it does not implement provisions in the proposed rule to cap payments for certain services at the hospital outpatient department or ambulatory surgery center rate. A new proposal governing a cap in payments at that rate will be released at a later date. In addition, the final fee schedule took statutory requirements and recommendations from the Medicare Economic Index Technical Advisory Panel into account to change the Geographic Practice Cost Indices.


The Department of Health and Human Services (HHS) released a report on Dec. 1, which stated a number of the administration's goals for improving the performance of Healthcare.gov have been met. For instance, the website is not crashing more than 90 percent of the time, while the rate at which consumers are encountering error messages is consistently well below 1 percent. In addition, the report noted that the average amount of time it takes for a consumer to bring up a page on the website is less than one second. HHS also said in its report that it believes the site can handle as many as 50,000 consumers simultaneously and as many as 800,000 visits each day. Jeffrey Zients, the Obama administration's point man on the effort to improve Healthcare.gov, said the number of people who accessed the site on Nov. 30 was higher than it had been since the first few days after the site was rolled out on Oct. 1. More than 16,000 people were on Healthcare.gov simultaneously during the peak traffic period, which occurred at about noon on Dec. 1. But several problems still need to be resolved, including issues associated with determining whether consumers are eligible for federal subsidies. In addition, some insurance companies are receiving duplicative enrollment files from the site, or files that contain missing or inaccurate information.


The number of Americans enrolled in Medicaid is expected to grow substantially over the next year, though it is not clear whether there will be enough doctors to treat these patients. According to the Congressional Budget Office, nine million people will enroll in Medicaid in the next year thanks to the expansion of the program in some states under the Affordable Care Act (ACA). According to the Congressional Budget Office, nine million people will enroll in Medicaid in the next year. The number of Medicaid enrollees is growing even in states that have decided not to expand the program, due to growing awareness about Medicaid following the passage of ACA. But, experts say that there may not be enough doctors to meet this demand given the fact that many doctors--particularly specialists--are not willing to accept new Medicaid patients due to the program's low reimbursement rates. There is anecdotal evidence that even patients who are able to find a doctor willing to see them are having to wait long periods of time to receive care. Some managed care companies are attempting to head off any problems by recruiting doctors and other healthcare providers to treat new Medicaid enrollees. However, some managed care companies say they are having trouble recruiting specialists.


The Centers for Medicare & Medicaid Services on Nov. 25 submitted a final version of the outpatient prospective payment system (OPPS) rule to the White House Office of Management and Budget. The rule includes changes to the Medicare hospital OPPS that take into account relevant statutory requirements and changes. In addition, the rule describes changes to the amounts and factors that are used to determine how much Medicare pays outpatient hospitals and ambulatory surgical centers for services rendered. The rule also finalizes the changes to the Ambulatory Surgical Center Payment System. All of the changes included in the rule will apply to services that are provided on or after January 1, 2014.


The Obama administration announced Nov. 22 that it was delaying several Affordable Care Act deadlines. The first deadline that is being extended is the deadline to enroll in an insurance plan that takes effect Jan. 1, 2014. Consumers previously had until Dec. 15 to enroll in an insurance plan that took effect at the beginning of next year, though problems with Healthcare.gov have forced the administration to push that date back to Dec. 23. Some in the insurance industry have expressed concern about the new deadline, saying that it gives them barely a week to process applications for insurance coverage that takes effect on New Year's Day. Inaccurate data provided by the government on Healthcare.gov enrollees could further complicate efforts to process applications, insurance industry officials have said. Applications that are not processed on time may leave some consumers without insurance coverage on Jan. 1, 2014. Meanwhile, the administration also announced that it was pushing back the start of the enrollment period for 2015 from Oct. 15, 2014 to Nov. 15. The Department of Health and Human Services said the delay will give insurers time to collect more data for use in setting 2015 rates.


The Senate Finance Committee has announced it will hold an "open executive session" on Dec. 12 to discuss repealing and replacing the Medicare sustainable growth-rate (SGR) physician payment formula. Representatives from physician organizations such as the Medical Group Management Association (MGMA) have said they are happy Congress is moving forward with efforts to repeal and replace SGR, though some also expressed concern that the Senate Finance Committee meeting is being held uncomfortably close to the date when SGR cuts are scheduled to take effect. If Congress fails to address SGR by the end of the year, doctors will face a 24.4 percent cut in Medicare payments beginning Jan. 1. Other healthcare industry groups, such as the American Medical Association (AMA) House of Delegates, have expressed concern about aspects of a proposal from Sens. Max Baucus (D-Mont.) and Orrin Hatch (R-Utah) that would repeal and replace SGR but also implement a 10-year payment freeze. AMA President Dr. Ardis Dee Hoven said freezing Medicare payments does not make sense because rates are already 20 percent less than the cost of providing care. Despite the objections to the payment freeze, Hoven said AMA needs to continue to be involved in the process of passing legislation to repeal and replace SGR.

Medicine, Drugs and Devices

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A study by the International Center for Limb Lengthening in Baltimore recommends using the Bebax orthosis over serial plaster casting to correct metatarsus adductus in infants who have not responded to simple observation or home stretching treatment. Twenty-seven infants (43 feet) between the ages of three and nine months who did not respond to home stretching treatment were randomized to either serial plaster casting to Bebax orthoses. Patients in the Bebax group displayed greater improvement in the footprint heel bisector measurement than the group of patients treated with serial plaster casts. In addition, Bebax treatment cost about half as much as casting. However, both groups of patients displayed improvements in footprint and radiographic measurements following treatment without a worsening of heel valgus. The study concluded that Bebax orthosis could be beneficial for infants with resistant metatarsus adductus whose parents are compliant, as the treatment requires more active parental cooperation than casting. The study also warned that some insurance plans may not pay for orthoses.


A recent study examined the accuracy of clinical presentation and four common clinical tests in diagnosing ankle syndesmosis injury. The study involved 87 patients who sought care at a clinic within two weeks after suffering an ankle sprain injury. Clinical presentation, dorsiflexion-external rotation stress test, dorsiflexion lunge with compression test, squeeze test and ankle syndesmosis ligament palpation were compared with magnetic resonance imaging (MRI) results as a reference standard. Researchers evaluated the tests using diagnostic accuracy, sensitivity, and likelihood ratios. They found that no one test was sufficiently accurate for diagnosing ankle syndesmosis injury. Researchers instead recommended combining sensitive and specific signs, symptoms and tests to confirm ankle syndesmosis involvement. An inability to hop, syndesmosis ligament tenderness, and the dorsiflexion-external rotation stress test (sensitive) could be combined with the pain out of proportion to injury and the squeeze test (specific), researchers said.