News From ACFAS

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We’re just 26 days away from celebrating 75 years of ACFAS! The 75^th Anniversary Scientific Conference, February 27–March 2 at The Mirage in Las Vegas, will bring together foot and ankle surgeons from across the country for superior learning, endless networking opportunities and sensational special events to put you on a permanent winning streak.

If you haven’t already registered for ACFAS 75, visit acfas.org/vegas today to get in on the action. Be sure to also book your room through onPeak at The Mirage or Treasure Island—rooms are still available but filling fast! Looking for a fresh perspective on the day-to-day issues affecting your practice? Then stop by the HUB theater from February 27 through March 1 during the 75^th Anniversary Scientific Conference at The Mirage in Las Vegas to hear how the experts keep their practices humming.

Located outside the Exhibit Hall this year, the HUB will deliver 50-minute presentations throughout each day. The casual atmosphere in this 45-seat theater encourages candid discussion and lively Q&A to give you practical solutions you can implement the minute you get home.

Download the free ACFAS 75 mobile app to check out updated HUB topics and to decide which sessions you’d like to attend. We’re once again making it easier for you to share your feedback on each session you attend during ACFAS 75 by using the evaluation tool in the free ACFAS 75 mobile app. Search your app store for ACFAS 75 to download the app to your mobile device. Your input on sessions for the 75^th Anniversary Scientific Conference February 27–March 2 at The Mirage in Las Vegas will help us determine topics for next year’s Annual Scientific Conference in Nashville. Nothing says professional more than a headshot that captures you at your best. Stop by Booth No. 1419 during the 75^th Anniversary Scientific Conference at The Mirage in Las Vegas to have your picture taken for free by a professional photographer through The HeadShotLounge™. Your photo session will include a brief touchup with a makeup artist, plus you’ll receive a hardcopy and digital version of your photo that same day so you can immediately add it to your resume and social media profiles.

Visit the photo booth on Tuesday, February 28, 9:30am–4pm, or Wednesday, March 1, 9:30am–2pm, to get your free headshot. Looking to jump into a fellowship right after you complete your residency? Then register now for the free webinar, Foot and Ankle Fellowships: Taking the Next Step, February 9, 2017 at 8pm CT.

This approximately 30-minute webinar will explore the decision-making process needed to commit to that extra year of training. Panelists include L. Marie Keplinger, DPM, FACFAS, past postgraduate fellow; J. Michael Miller, DPM, FACFAS, fellowship director of the American Health Network Foot & Ankle Reconstructive Surgery Fellowship; and Heidi Godoy, DPM, resident and member of the ACFAS Membership Committee.

Topics will include:

• Why fellows choose to do a fellowship.
• When to start looking.
• How to choose a program.
• How fellowships compare to residency training.
• What fellowship programs are looking for in a candidate.

Foot and Ankle Surgery

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A retrospective cohort study examined the risk of remote-site invasive systemic infection related to diabetic foot ulcers (DFU-ISI) after hospitalization. The study included 819 patients living with diabetes who had been hospitalized for 1,212 diabetic foot ulcers (DFUs) during a nine-year period. Researchers found 141 patients had 172 DFU-ISIs after DFU hospitalization. Of the initial DFU-ISIs, 64 percent were bacteremia, 13 percent deep abscesses, 10 percent pneumonia, seven percent endocarditis and six percent skeletal infections. Methicillin-resistant Staphylococcus aureus (MRSA) was the cause of 57 percent of the ISIs. Patients with initial DFU cultures showing MRSA and protracted open ulcers had a high 24-month cumulative probability of ISI and all-cause mortality rate.


Plantar shear stress and its relevance to diabetic foot ulcers (DFUs) have yet to be studied extensively, so a recent study aimed to compare peak shear in individuals with DFU to patients with diabetic neuropathy (DN) but no history of DFU. Researchers quantified peak plantar shear and peak pressure in nine patients with DFU and 16 patients with DN. Pressure and shear data was collected while barefoot subjects walked across the Cleveland Clinic shear plate. Peak pressure was not significantly different between the two groups, but peak shear was significantly higher in the DFU group (DFU: 135.3 kPa, DN: 86.4 kPa).


Researchers evaluated the effects of aging on healthy Achilles tendons and aponeurosis shear wave speed (SWS) by using shear wave elastography to measure spatial variations. The study included 15 young adults, 10 middle-aged adults and 10 older adults. SWS was measured in the free Achilles tendon, soleus aponeurosis and gastrocnemius aponeurosis in resting, stretched and slack postures. SWS was found to significantly increase with stretch and vary with age in all tendon regions. Slack free tendon SWS was significantly higher in older adults than young adults, but stretched soleus aponeurosis SWS was lower in older adults than young adults. Stretched gastrocnemius aponeurosis SWS was lower in both middle-aged and older adults compared with younger adults.

Practice Management

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The Fair Labor Standards Act does not require employers to pay employees for federal holidays or other time not worked, but 90 percent of businesses offer employees six paid holidays per year, according to the Society for Human Resource Management’s (SHRM) 2017 survey. Paid time off is a more valuable benefit than many employers realize. A CakeHR survey found that while chief financial officers believe benefits packages, flexibility and professional development are the most important factors in employee retention, employees say paid time off is a top priority. Potential employees should be told upfront if a practice does not make paid holidays a part of its benefits package. Employers that offer paid holidays should make clear which holidays the practice considers to be paid days off and the level of compensation for those days. If a practice is unable to offer holidays off, employees may earn additional pay for working on a holiday. SHRM's survey found that 57 percent of businesses give employees extra pay when they are required to work on a holiday, with 40 percent of these offering double-time pay.


Record numbers of hospitals, medical facilities and physician practices fell victim to ransomware attacks in 2016. Ransomware is a type of malicious software that locks a user’s data until a ransom is paid. When electronic health record systems are targeted, providers feel compelled to pay the ransom to regain access to their files rather than interrupt patient care. According to the U.S. Department of Health and Human Services (HHS), the presence of ransomware is considered a security incident under the Health Insurance Portability and Accountability Act (HIPAA) security rule. Any electronic protected health information encrypted by ransomware is presumed a “breach,” requiring a covered entity to proceed with their breach notification obligations. These breach notification rules can compromise the reputation of a provider, as notification of patients, the Secretary of HHS and the media may be required. To prevent ransomware attacks, HHS guidance recommends that providers follow the HIPAA security rule and implement a robust data backup plan. Providers also are urged to invest in security software, including firewalls and anti-virus programs, and frequently install updates. Once a ransomware attack is identified, providers should follow their security incident response plan, which involves conducting an initial analysis, containing the infection, eradicating instances of ransomware and recovering from the attack by restoring backups.


A payer’s error on an explanation of benefits (EOB) may cause payments to be withheld from a practice. In one case, a large payer had stopped listing a deduction on the multiple procedure payment reduction on a practice’s 2017 claims and had been charging the practice for not meeting specific criteria through their electronic health record (EHR) system. The EHR company filed an appeal to the payer, who acknowledged the mistake but continued to subtract payments while they worked to remedy the situation. The practice also found the payer was taking subtractions for a new staff member for not following reporting guidelines in 2015, despite the employee not reporting until 2016. The payer has agreed to repay the subtracted payments, a process which could take up to six months. Practices should carefully review their EOBs to ensure all payers are paying the amount stated in the contract and that all deductions are identified and valid.

Health Policy and Reimbursement

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President Donald Trump has issued an executive order urging agency heads to waive or delay Affordable Care Act (ACA) provisions they deem burdensome. It is unclear how many provisions officials will choose to target or when their actions will be implemented. Officials may choose to neutralize penalties for individuals who are uninsured and set the stage for insurers to offer plans with fewer benefits and sell insurance across state lines. The order does not repeal the ACA and does not strip away funding for coverage from people who are currently enrolled. However, the move indicates the new administration will take swift action to dismantle parts of the ACA, with a focus on eliminating the provisions requiring individuals to buy insurance. While removing the mandate would be popular in some regions, it could set in motion a chain of events that would lead to the collapse of the individual insurance market if no other steps are taken.


Two Republican senators on Monday proposed a healthcare bill that allows states to opt out of major parts of the Affordable Care Act (ACA). Under the Patient Freedom Act of 2017, states could choose to drop several provisions, including the coverage mandate and the edict against insurers charging older people significantly more than younger people. States that drop the ACA would need to keep some requirements imposed on insurance companies intact; insurers would need to allow children to stay on their parents’ plan until age 26, pay claims without annual or lifetime limits and issue policies to individuals with preexisting conditions. States could also choose to collect the federal funds that would have gone toward tax credits and Medicaid expansion and use the money to enact their own healthcare programs. Sens. Susan Collins (R-Maine) and Bill Cassidy (R-La.) say their bill is the only approach with a chance of unifying congressional Republicans and the handful of Democrats needed to pass a complete ACA replacement.


Rep. Tom Price (R-Ga.), President Donald Trump’s nominee to lead the U.S. Department of Health and Human Services, believes the electronic health record (EHR) incentive programs and their meaningful use requirements obstruct provider productivity and health outcomes. During his Senate hearing last week, Price spoke favorably on EHRs and their role in care continuity. However, he maintains that the final regulations related to meaningful use requirements have handcuffed physicians and detracted from their ability to engage with patients and provide quality care. Price recommends implementing fewer reporting requirements and keeping rules that focus on outcomes rather than provider actions. The College of Healthcare Information Management Executives last month published a letter asking policymakers to improve the flexibility of meaningful use requirements. These recommendations include a single set of health information technology standards, aligned quality reporting requirements across provider settings and a 90-day meaningful use reporting period for 2017 and 2018.

Medicine, Drugs and Devices

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A new study aimed to introduce a new screw fixation technique for isolated talonavicular arthrodesis (TNA) and evaluate the clinical outcomes of individual headless compression screws (HCSs) applied with 3D image processing technology. Sixty-nine patients underwent isolated TNA with double Acutrak HCSs. One HCS was oriented antegradely from the edge of the dorsal navicular tail where it intersected between the first and second cuneiform into the talus body along the talus axis. The other HCS paralleled the first screw and was oriented from the dorsal-medial navicular where it intersected at the medial plane of the first cuneiform. Postoperative assessment included the American Orthopedic Foot & Ankle Society (AOFAS) hindfoot score and the visual analogue score (VAS). At 44-months mean follow-up, all patients demonstrated good articular congruity and solid bone fusion at an average of 11.26 weeks. Overall fusion rates were 100 percent. The average AOFAS score increased from 46.62 to 74.77 at final follow-up. The mean VAS score decreased from 7.01 to 1.93. One patient experienced wound infection, and three patients experienced adjacent arthritis.


Recent studies suggest Latino patients with limited English skills may be less likely to adhere to prescribed diabetes medications than other people living with diabetes in the United States. A study published in JAMA Internal Medicine evaluated 31,000 patients living with diabetes who received insurance and healthcare through Kaiser Permanente in Northern California. About 60 percent of Spanish-speaking Latino patients did not fill their prescriptions at least 20 percent of the time. The rate was about 52 percent for English-speaking Latino patients and 38 percent among white patients. The study did not find any difference in medication adherence for people living with diabetes who saw Spanish-speaking doctors. However, a second study of Kaiser Permanente patients published in the same journal claims Latinos living with diabetes who have limited English proficiency have better blood sugar control when they switch from English-speaking to Spanish-speaking primary care physicians. After switching to Spanish-speaking doctors, 74 percent of patients had blood sugar in a healthy range, up from 63 percent when they saw English-speaking doctors.


President Donald Trump is considering imposing a 20 percent tax on imports from Mexico to pay for his proposed wall along the southern border, potentially causing cost hikes for medical products imported from Mexico. Census data shows that Mexico exported to the United States more than $5.4 billion of medical, surgical, dental or veterinary instruments between January and November 2016. The United States imported from Mexico $758.1 million in orthopaedic appliances, artificial body parts and hearing aids; $153.6 million in x-ray equipment and accessories and $360.6 million in pharmaceutical products. Mexico is the fourth biggest exporter to the United States of orthopaedic appliances, artificial body parts and hearing aids. However, imports from Mexico represent a small portion of all imports, as the United States sources products from a variety of countries. U.S. companies also export significantly more of these products to other countries than the United States receives from Mexico. Nevertheless, an additional tax on any imported healthcare products could cause problems for hospitals and their group purchasing organizations.