News From ACFAS

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See hallux valgus and the second MTPJ from an entirely new angle—check out two new free clinical sessions available now in the ACFAS e-Learning Portal:

• Century of Hallux Valgus: Evolution of Treatment
• The Obstinate 2^nd MTPJ

Each session includes presentations with leading experts who outline new approaches and corrective techniques for treating bunions and second MTPJ injuries and deformities. Access these sessions anytime, anywhere for convenient learning that also gives ACFAS members the chance to earn CME credit.

Visit acfas.org/e-learning for the complete clinical session library plus monthly podcasts, downloadable Surgical Techniques videos, e-Books and other resources, all just a click away. Without your research, podiatric medicine stands still. Help maintain the profession’s forward momentum by submitting your manuscript to the College’s annual manuscript competition at ACFAS 2018.

Scheduled for March 22–25, 2018 in Nashville, the competition spotlights the latest advancements in foot and ankle surgery. All manuscripts submitted for consideration are blind-reviewed and judged on established criteria. Winners divide $10,000 in prize money.

Submissions for the 2018 competition are due September 15, 2017. Check acfas.org during the summer for submission guidelines and criteria. Physicians have until May 15, 2017 to review and dispute data reported by drug and medical device makers before this information is made to the public on June 30, 2017.

Registration is required to review and dispute data. Visit cms.gov for more information on the registration process.

The College requires all volunteers to review their Open Payments information as part of their conflict of interest questionnaire.

Foot and Ankle Surgery

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A study was conducted to probe the categorized impact of estimated glomerular filtration (eGFR) on the outcomes of patients with diabetic foot ulcers (DFU). A cohort of 366 DFU patients hospitalized in a Chinese tertiary hospital were enrolled and classified into four groups as normal, mildly reduced, moderately reduced and severely reduced. The patients were followed up for an average of 37 months. Compared to patients with normal eGFR, patients with moderately reduced eGFR had a higher risk of healing failure, cardiac events and death. Severely reduced eGFR was associated with a higher incidence of healing failure and death. The effect of eGFR on ulcer recurrence and cerebrovascular events was not noted among all groups.


The results of a new study presented at the American Institute of Ultrasound in Medicine annual meeting indicate shear-wave elastography is sensitive and specific for spotting Achilles tendinopathy, and it can function as a more objective technique than other imaging modalities for diagnosis and treatment. Twelve patients with unilateral, moderate to severe Achilles tendinopathy underwent shear-wave elastography. At a threshold shear-wave speed of 12 m/sec, shear-wave imaging generated 92 percent sensitivity and 83 percent specificity for diagnosing moderate to severe Achilles tendinopathy. The patients' tendinopathic side was substantially thicker than the contralateral side, but the control side was significantly thicker than expected from a normal tendon. The tendinopathic tendons were also more hyperemic than the contralateral side and exhibited greater echogenicity. Still, the contralateral side had more hypoechogenicity than what has been detailed in the literature. In addition, the shear-wave speed on the tendinopathic side was lower than on the contralateral side.


Researchers conducted a study to assess the incidence of abnormal internal rotation of the talus in the axial plane in patients with varus ankle osteoarthritis (OA) and to determine whether this incidence differs with the severity of varus ankle osteoarthritis. They evaluated weightbearing computed tomography and plain radiographs of 52 ankles with no abnormalities and 96 ankles with varus osteoarthritis, which were further stratified into a moderate OA subgroup and a severe OA subgroup. In the varus OA group, the incidence of abnormal internal rotation of the talus was 45 percent, which corresponded to an incidence of 32 percent in the moderate OA subgroup and 59 percent in the severe OA subgroup. The study demonstrated that abnormal internal rotation of the talus occurs in patients with varus ankle osteoarthritis and is more frequently noted in severe than in moderate varus ankle osteoarthritis.

Practice Management

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One option for doctors to generate more revenue is by adding a physician extender, typically a nurse practitioner (NP) or physician assistant (PA). While not cheap, an extender could help a practice grow revenue by up to 20 percent, experts say, but only if patient demand warrants the hire. "It's really important that practices always have [available appointments] for their patients," observes Judy Treharne, a consulting executive at Halley Consulting Group. "This is true not just for existing patients, but also for new patients because of the necessity for a practice to be growing." If sufficient demand exists, extenders can add significant profits to a practice's bottom line, experts say. "Primary care doctors should make $20,000 to $45,000 in profit from an extender," according to Deb Phairas, president of Practice & Liability Consultants. Treharne says skill set, not cost, should be the determining factor in the type of extender to hire. NPs, because of their nursing background, tend to have more experience in assessing and caring for patients in a clinic setting. "They want people to stay healthy and stay out of the office, so this could help you get points for quality measurements," notes Phairas. Treharne adds that physicians should not wait until they are desperate to hire an extender because it can take six months or longer to find the right person, not including the time spent reviewing resumes and interviewing applicants. Extenders also need to be credentialed with health plans, which can take 90 to 120 days.


For primary care physicians (PCPs) to succeed under the Merit-based Incentive Payment System (MIPS), significant revisions will be required in their delivery of care and their tracking and reportage of patient outcomes. Success under MIPS will initially depend on the extent of practices' previous participation in value-based programs and reporting. MIPS will be less difficult for those experienced with collecting and reporting data for programs, such as the Physician Quality Reporting System (PQRS) and Meaningful Use (MU). MIPS permits PCPs to be rated as individuals or as a group, with "virtual groups" to be allowed starting next year. It is vital that practices follow MIPS procedures precisely this year as they will not know if they have made errors in collecting and disclosing this year's data until they get their 2019 payments. Experts advise not banking on an increase in Medicare reimbursements and building in a margin in case reimbursements are penalized or anticipated bonuses are not forthcoming. It is important to know that MIPS quality measures are largely identical to those in the PQRS and Value-Based Payment Modifier (VBM) programs. MIPS also calculates one population measure for groups with 16 or more clinicians and a minimum of 200 cases. Practices can secure bonuses for activities such as reporting outcomes, appropriate use and electronic health record reporting. Practices must also must engage in four medium-weighted or two high-weighted clinical practice improvement activities to fully participate in MIPS. As a replacement for MU, practices must report on five measures: security risk analysis, e-prescribing, patient electronic access and requesting/accepting a summary of care document. Finally, the VBM program is supplanted by cost or resource use metrics.


KPMG's Digital Health Pulse 2017 survey of 147 hospital executives asked them about the state of adoption for virtual care services and the leading challenges for hospitals and healthcare systems in digital health. The poll estimated 31 percent of healthcare organizations currently use video-based services and 34 percent offer remote patient monitoring. About 50 percent of providers reported having clinician-to-clinician consults or continuous monitoring via telestroke or teleICU services. However, just 4.5 percent said they had an Advanced Virtual Care Program, with central governance and standard clinical workflow, technology solution and KPI reporting, supporting more than five service lines. Forty-five percent of respondents noted "the time is right, and we are just beginning with one or two pilot projects." Another 28.8 percent described their programs as having "early program investments with less than three FTE staff supporting the network for two-plus service lines across the organization." Maintaining a sustainable business and/or financial model was cited by 25 percent of respondents as the biggest challenge in virtual care. The analysts expect the transition from fee-for-service to value-based care will be a key driver of telehealth adoption.


Organized cybercrime groups featuring hackers are starting to target medical practices in an attempt to gain access to credit card numbers, Social Security numbers, email addresses, bank account information and birth dates. Small businesses, such as medical practices, are often less secure than their larger counterparts, but cybersecurity experts say there are ways they can protect themselves from cybercriminals. At a minimum, practices' IT security framework should include deploying technical controls, such as firewalls, desktop antivirus software, antivirus software on email servers, antivirus and antimalware protection on employee inboxes and content filtering for the Internet and email. With regard to the Internet, a software firewall is typically appropriate for small physician practices. Healthcare providers should require training that introduces employees to the threat environment, helps them understand the risks of different decisions and motivates behavioral changes. Practices should use strong passwords, restrict access to patient data that is considered protected health information (PHI) under HIPAA on an as-needed basis and send emails securely. Also, for mobile devices, practices should encrypt PHI, install personal firewall software, regularly update virus protection software and protect passwords.

Health Policy and Reimbursement

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Residents and physicians who have just completed their residency are angered at the Accreditation Council for Graduate Medical Education's (ACGME) decision to extend hourly restrictions for interns from 16 to 28 hours. The amended hours cap interns at a maximum of 24 hours on a shift, plus up to four additional hours to manage care transition time, according to an ACGME memo from ACGME CEO Thomas J. Nasca. In 2011, ACGME had limited interns' hours to 16 for each shift, and the change reverts first-year residents to the same schedule as more advanced residents and fellows. "These changes point to the overall question of how we are overseeing our residents' well-being," says Cambridge Health Alliance intern Samantha Harrington. "This is a step in the wrong direction." Jason Sood, a second-year family medicine resident at several hospitals of the Rowan School of Osteopathic Medicine, says the changes do not come as a surprise. "Hospitals, for their bottom line, it makes sense not having to hire physician extenders," he notes. "We're cheap labor." The Committee for Interns and Residents' Heather Appel says union members are not only worried about the long shifts, but also about ACGME's language revisions, eliminating the word "honest" from a statement that residents are required to accurately report their hours.


California Assembly member David Chiu has proposed bolstering intra-agency collaboration on drug cost-saving strategies by encouraging state health programs to pool together to negotiate better prices with drugmakers. "Californians and Americans are frustrated with the lack of progress around drug prices," Chiu says. He argues state agencies' unified efforts should enable them to "leverage that consumer power and get the best deal for our money." Chiu's California Drug Costs Reduction Act does not require California health programs, such as Medi-Cal or Covered California, to procure drugs together, but it would mandate administrators of those programs and 17 other state agencies to convene biannually to strategize about ways to keep costs down. State officials would consider a uniform state drug formulary and weigh paying for drugs according to the value they bring to the health system via the California Pharmaceutical Collaborative (CPC). Chiu's legislation would require yearly reports from CPC, which he says would ensure greater accountability.


The latest version of the American Health Care Act (AHCA) has been criticized by a coalition of six physicians' groups in a letter to Congress. Current law stipulates all health insurance policies must feature 10 essential health benefits, and it bans a yearly or lifetime cap on claims in those categories. The coalition warns that the dismantling of those protections could prevent some individuals from getting care and could spur discriminatory coverage. The ACHA would permit each state to choose how it would regulate health insurance, as long as they could justify the exit from current patient protections. "We believe that pending legislation proposals would dramatically increase costs for older individuals, result in millions of people losing their healthcare coverage, and return to a system that allows for discrimination against people with preexisting conditions," the letter states. The coalition, representing more than 560,000 physicians, says if the ACHA became law, insurers could deny payment for substance abuse treatment for millions, "when such services are needed more than ever to address the opioid epidemic in the United States." In addition, the high-risk pools proposal—which some states might deploy in order to slash prices for healthy customers—would be underfunded. The coalition emphasizes this particular solution has "been proven ineffective numerous times."

Medicine, Drugs and Devices

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A study was conducted to assess the total ankle replacement (TAR) procedure in the setting of prior arthrodesis. The researchers set out to determine what intraoperative and perioperative complications occurred in 18 patients who underwent conversion of an ankle arthrodesis to a TAR. They also investigated whether durable fixation was achieved at short term and what the alignment of the components was. Other issues included what subsequent surgical procedures were performed and what improvements in pain, tibiotalar range of motion (ROM) and quality of life were observed. Two of the 18 patients sustained an intraoperative medial malleolar fracture, and delayed wound healing was observed in three patients. At the latest follow-up, four patients had incomplete osseointegration, and none of the patients had prosthesis loosening. Both components were neutrally aligned in all patients. Two patients exhibited painful arthrofibrosis with reduced ROM, which was treated with an open arthrolysis and exchange of mobile-bearing inlay. One other patient is mulling a revision for substantial tibial component medial tilt with collapse of the medial arch.


New research suggests that the shoelace closure technique can have a profound effect on plantar thermal stress response (TSR). The left foot was used as a reference and fitted to a self-adjusted and habitual lace-tightening method for 15 subjects. The right foot was used as a test closure and fitted into three lace closure conditions: loose, tight and preset optimal closure (reel clutch, BOA technology). Thermal images were taken after five minutes of acclimatization (pretrial) and immediately after 200 walking steps in each shoe closure condition (posttrial). TSR, calculated from the thermal images, was significantly higher in the test closure with loose (70.24 percent, P = .000) and tight (66.85 percent, P = .007) and lower (-206.53 percent, P = .000) in the preset optimal closure when compared to the reference closure. Only lace closure conditions affected TSR with no significant impact of age, BMI and gender in the sample as assessed in a multivariable regression model. The researchers say it stands to reason that optimal lace closure may have an impact in reducing risk of plantar ulcers in people with diabetic peripheral neuropathy (DPN).


Local intraoperative infiltration of liposomal bupivacaine administered with standard bupivacaine for ankle fractures requiring open reduction internal fixation affords improved pain relief in the immediate postoperative period, according to a new study. Researchers randomly assigned 39 patients to one of two groups, control (local intraoperative sterile saline injection under general anesthesia) or interventional (local intraoperative liposomal bupivacaine and bupivacaine injection under general anesthesia). Administered in a standardized fashion, injections included a 1:1 mixture of a 40cc solution consisting of 1.3 percent Exparel and sterile saline (interventional) or a 40 cc injection of normal saline (control) into the surrounding periosteal, peritendinous, surrounding muscles and subcutaneous tissue of the surgical incision. Pain scores were significantly lower in the interventional group versus control up to two weeks after surgery. Percocet ingestion at four hours was significantly lower in the interventional group (0.7 vs. 1.3, p=0.004), while it approached significance at 48 hours postoperatively (2.8 vs. 3.69, p=0.07). No other significant differences were noted for Percocet ingestion postoperatively at other time points assessed. The overall satisfaction with pain control was not statistically different between the two groups (p=0.93).