News From ACFAS

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Need to speak at an upcoming health education event but don’t have a presentation handy? ACFAS has a library of popular patient education PowerPoint presentations, with scripts, easily customizable and accessible for download in the ACFAS Marketing Toolbox. Topics include: Bunions and Hammertoes; Common Athletic Injuries of the Ankle; Heel Pain; Ankle Arthritis; and the latest addition to the library, Common Foot and Ankle Conditions.

Each presentation provides a condition overview, outlines symptoms and treatment options and includes a customizable slide for your practice’s contact information so new and existing patients can reach you. All presentations are also accompanied by a fully written script to coincide with each slide for you to use during your talk.

Remember, the ACFAS Marketing Toolbox has everything you need to promote your practice, from the seasonal FootNotes patient newsletter to press release templates to patient education CDs and much more! Keep checking for updates and new products.
If you or your practice have moved to a new address recently, be sure to log into your ACFAS account at acfas.org/profile to update your contact information so you can continue to receive valuable College communications.

While you're in your profile, you can also:

1. Update your work or personal email addresses as well as your fax number and work, home or cell number.
2. Confirm the Journal of Foot & Ankle Surgery and other ACFAS publications are reaching your preferred address.
3. Share your contact information with your colleagues through the College’s online members-only directory.
4. Include yourself in FootHealthFacts.org's Find an ACFAS Physician search tool. Simply click yes for Consumer Physician Search.

Keep your profile updated so your fellow members, potential patients and ACFAS can keep in touch with you! To support future researchers close to home, nine of ACFAS’s 14 Regional Divisions provided funds to 60 resident poster presenters and two resident manuscript presenters at ACFAS 2015 in Phoenix.

Resident poster presenters received $250 in support, and resident manuscript presenters received $500. To claim their funds, residents needed to submit an application to their Division, have their research accepted for presentation at the conference, attend the conference and also attend their Division’s membership meeting during the event. The Division officers plan to offer this support again in 2016.

To see which residents received support in your area this year, visit your Division’s webpage.

Foot and Ankle Surgery

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Since nonunion risk factor identification and modification are subjective, a research group set out to describe and validate a predictive model to identify patients at risk for nonunion in foot and ankle surgery. One hundred international experts were surveyed. A total nonunion risk (TNR) score was calculated for individual patients. It was retrospectively validated in 2 patient cohorts from a single center's prospectively collected end-stage ankle arthritis patient database: 22 cases of ankle and/or hindfoot fusion nonunion and 40 sex- and procedure-matched controls with bony fusion. The mean TNR score was 6.6 ± 5.6 in controls and 13.5 ± 8.2 in the nonunion group (P < .001). In a logistic regression model, the risk of nonunion exceeded 9 percent with a TNR score greater than or equal to 10. Multivariate linear regression analysis, adjusted for age and sex, suggested that lack of fusion, site stability and obesity (body mass index greater than 30) were significantly predictive of nonunion.


A study was conducted to analyze the outcomes of lateral column lengthening with porous titanium wedges compared to historic controls of iliac crest autograft and allograft. The goal was to test if a porous titanium wedge would yield radiographic improvement and union rates similar to those using autograft and allograft. Twenty-eight feet in 26 patients were treated using a porous titanium wedge. The results showed that patients had significant deformity correction in the anteroposterior talo-first metatarsal angle, talonavicular coverage angle, lateral talo-first metatarsal angle and calcaneal pitch. All but one patient had bony incorporation of the wedge. All patients but three had improvements over their pre-operation pain score.


A study was conducted to determine the role of the bone-regulating Wnt/ß-Catenin and RANK (receptor activator of nuclear factor-kappa B)/OPG (osteoprotegerin) pathways in Charcot arthropathy. Twenty-four consecutive patients were treated by off-loading and were monitored by foot radiography and MRI for circulating levels of sclerostin, dickkopf-1, Wnt inhibitory factor-1, Wnt ligand-1, OPG and RANK for two years. The results suggested that high plasma RANK ligand (RANKL) and OPG levels at diagnosis of Charcot indicate that there is high bone remodeling activity. These levels gradually normalize after off-loading treatment. The consistently balanced OPG/RANKL ratio in Charcot patients suggests that there is low-key net bone building activity by this pathway following diagnosis and treatment. Inter-group differences at diagnosis and changes in Wnt signaling following off-loading treatment were sufficiently large to be reflected by systemic levels, indicating that this pathway has a role in bone remodeling and bone repair activity in Charcot patients.

Practice Management

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Adherence to the new ICD-10 is required by October 2015, so physicians are scrambling to prepare for 70,000 new diagnosis codes and the troubles that come with a wholesale change. Physicians should properly prepare for five imminent issues to ensure a smooth transition. To prevent an excess of queries regarding coding, be sure to drive out unspecified diagnosis codes in ICD-9. Run a frequency report on the most commonly ordered diagnostic tests for certain conditions and put those codes into a favorites file to ensure a prompt conclusion to an office visit. Peruse your patients' coverage policies so that denials due to medical necessity diagnosis coding become less frequent. Increase coding capacity and expertise so that the process for diagnosis coding is simple. This will prevent a loss of cash flow and prevent perpetual confusion. Finally, educate clinicians and give them as much help as necessary. A frustrated, overwhelmed clinician is one prone to critical errors, so train them on only the most important parts of ICD-10. Lighten schedules and put station coders in convenient places around the office to ensure optimum speed and efficiency. Putting all of this together will make for a smooth transition and keep problems to a minimum.


A University of Colorado study reports that giving hospitalized patients access to their electronic health records (EHRs) during hospitalization increases provider workloads although not as much as expected. In the study, 50 patients were provided with tablets during hospital stays, enabling them to view their EHRs via a patient portal. Before patients saw their EHRs, 68 percent of surveyed physicians and all surveyed nurses believed that it would result in additional work for them. However, after patients viewed their records, only 36 percent of doctors and half of nurses reported larger workloads. Before gaining access to their records, 92 percent of patients felt seeing their EHRs would allow them to better understand their medical conditions, and 80 percent indicated they expected it to help them understand their providers' instructions. After viewing their EHRs, 82 percent said they better understood their medical conditions, while 60 percent said it helped them understand instructions.


Medical practices can follow a number of telephone etiquette suggestions that add no costs and can boost staff productivity and even reduce risk. Those suggestions include:

1. Having receptionists offer to take a message if they are unprepared to deal immediately with the caller. This would be a better alternative to patients than being put on hold for long periods, while staff and physicians would benefit if the calls were addressed in batches, on a schedule. Moreover, there would be no interruption in workflow.
2. Asking patients if they can hold and wait for an answer before putting them on hold. This avoids giving patients the impression that they are automatically being ignored.
3. Not allowing the phone to ring too many times to avoid trying callers' patience and compounding their frustration. If no one is able to answer a call within two or three rings, the message to callers is that the practice's staff is otherwise occupied. A prompt rollover to voicemail can also be less frustrating to callers.
4. Telling callers when to expect a response when taking a message, with the goal of minimizing uncertainty and managing expectations. If callers know there will be no callback until the clinic session is over, they will not expect one sooner. This tip only works when physicians and staffers keep the practice's promises to patients.

Health Policy and Reimbursement

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The U.S. Supreme Court has ruled that private Medicaid providers cannot sue to force states to raise reimbursement rates. The decision is a blow to many doctors and healthcare companies, which argue that state Medicaid reimbursement rates are so low that healthcare providers often lose money on Medicaid patients. In 2009, Idaho centers that provided care for about 6,200 mentally disabled children and adults challenged the state's Medicaid reimbursement rates in court. The centers argue that the state had adopted a Medicaid plan with reimbursement rates set at 2006 levels, despite the fact that costs had increased significantly in the three years since. The lower courts agreed and raised the state's reimbursement rates, but the Supreme Court reversed the ruling, declaring that private Medicaid providers had no right to sue under Medicaid law. The court said if a state is not providing fair reimbursement rates, the only recourse Medicaid providers have is to ask the federal Department of Health and Human Services to withhold all Medicaid funds from the state, which has never happened.


The U.S. Supreme Court recently declined to hear a new challenge to President Obama's healthcare law that aimed at a bureaucratic board intended to cut Medicare costs. The board has been labeled a "death panel" by some Republicans opposed to the Affordable Care Act. In the case, Arizona-based business owner Nick Coons and Dr. Eric Novack, an orthopedic surgeon, sued in 2011 in litigation backed by a conservative legal group. Among other things, they challenged the Independent Payment Advisory Board (IPAB). Lower courts threw out the lawsuit. In its August 2014 ruling, the appeals court said that the plaintiffs had not shown they had suffered any harm that they could sue over. In the current case, the court noted that under the terms of the healthcare law, IPAB acts only if Medicare spending increases at a certain level. The earliest it could ever take any action that could potentially reduce Novack’s Medicare reimbursements would be in four years.

Medicine, Drugs and Devices

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The White House has directed the Centers for Disease Control and Prevention (CDC) to cut rates of infections from antibiotic-resistant bacteria by 2020 and to stop the overuse of antibiotics given to humans and animals. President Barack Obama wants the CDC to lower carbapenem-resistant Enterobacteriaceae (CRE) infections by 60 percent and clostridium difficile and MRSA infections by 50 percent by the end of the decade. CDC plans to develop surveillance programs with the help of hospitals and health departments to monitor and reduce infections and to promote antibiotic stewardship programs. Although the agency collects drug-resistant infection data from 5,000 U.S. hospitals, just 70 facilities connect to the national database that submits data on antibiotic prescription patterns—a number CDC hopes to increase. Meanwhile, CDC has highlighted the success of the Chicago Prevention Epicenter program that enabled four long-term acute-care hospitals to halve the number of infections caused by CRE bacteria over a three-year period. Under the program, all patients were tested for CRE infections when they were admitted and two weeks later. Those who developed CRE were given private rooms or placed in a ward with other CRE-infected patients, treated by healthcare workers wearing protective gowns and bathed in the antiseptic chlorhexidine gluconate.


Hospitals are learning that it is nearly impossible to clean endoscopes responsible for spreading deadly bacteria that have resulted in lawsuits from patients and have led device regulators to search for a solution. A Seattle hospital where a fatal drug-resistant superbug was spread by contaminated scopes is still finding germs on the instruments even after strengthening its cleaning procedures. After an outbreak that affected 32 patients, including 11 deaths, Virginia Mason Medical Center redoubled efforts to clean the scopes with "meticulous manual cleaning" and started taking the instruments out of service for 48 hours between procedures and culturing them to check for bacteria. Even with the improved cleaning, the hospital found that 3 percent of the scopes tested positive for contamination and needed to be recleaned.


The U.S. Food and Drug Administration (FDA) has announced it will give the technology industry leeway to develop new products without aggressive regulation. Bakul Patel, FDA's associate director for digital health, says most wearable gadgets like the upcoming Apple Watch and health-focused applications for smartphones need more development before they warrant closer scrutiny from FDA. "We are taking a very light touch, an almost hands-off approach," said Patel. "If you have technology that will motivate a person to stay healthy, that's not something we want to be engaged in."


Variations in how physicians use medical devices have a significant effect on patient outcomes and costs, according to an analysis by the University HealthSystem Consortium. The study examined physician preference items at 10 academic medical centers and found costs differed for cases involving items like orthopedic implants, coronary and peripheral stents and cardiac valves. The cost of procedures like hip replacements were higher at one hospital based on a physician's preference to use a more expensive, customized implant, even when less expensive options would have been medically appropriate. Using customized implants also resulted in longer patient stays and higher readmission rates for those patients compared to other physicians' patients.