News From ACFAS

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Ready for a new advanced Surgical Skills course that gives you fresh, unbiased views of the latest treatment approaches for athletes of all ages and fitness levels? Then sign up now for The Athlete’s Foot & Ankle: New Trends, Management and Surgical Treatments, October 8–9 at the Orthopaedic Learning Center in Chicago, and learn how to create a game plan for treating sports injuries while strengthening your arthroscopic technique.

This course follows two one-day tracks—Open Procedures (Track A) and Advanced Arthroscopy (Track B)—that include hands-on cadaveric lab time plus case-based and panel discussions with faculty. Bring radiographs of your cases on a flash drive to Sunday evening’s dinner and fireside chat for feedback and solutions from experts in sports medicine.

Visit acfas.org/skills to register today since spots for this course are limited. ACFAS offers a Student-Transitional membership category for unmatched residents who have not yet found placement within a program. The membership provides graduated students a one-year transitional membership at no cost.

Through ACFAS, graduated students without a residency match can:

• access The Journal of Foot & Ankle Surgery online
• receive student pricing for all ACFAS educational offerings
• network with ACFAS members who can assist in their search for a residency match

Contact the ACFAS Membership Department at (773) 693-9300 for more information. ACFAS wants to know if you use telemedicine to treat your patients. Vote in this month’s poll at right to share your input, and visit acfas.org throughout July to see up-to-the-minute results.

Foot and Ankle Surgery

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A new study focuses on the safety and efficacy of bone marrow mobilization with granulocyte colony-stimulating factor (G-CSF) for lower-limb ischemia. Researchers randomly assigned 44 patients to receive two injections of G-CSF (300 micrograms) prior to bone marrow mononuclear cell (BM-MNC) transplantation. BM-MNCs were harvested from all patients and injected as equal aliquots of at least 108 cells into the ischemic leg muscles below the lowest patent artery. After three months, patients receiving G-CSF reported increased subjective relief of symptoms and showed increased transcutaneous oxygen tension. After six months, patients showed greater improvement in TcPO2, ankle-brachial index and angiographic score compared to control patients. There were no increased numbers of side effects in patients receiving G-CSF. Researchers conclude that G-CSF is safe and effective to mobilize BM-MNCs and may allow reduced volume of aspirated bone marrow, potentially reducing procedural complications. G-CSF should be considered for use in patients who are candidates for angiogenic therapy.


A study was conducted to assess whether baseline magnetic resonance imaging (MRI) parameters provide prognostic value for clinical outcome and to study correlation between MRI parameters and clinical outcome. Twenty-five patients with chronic midportion Achilles tendinopathy were enrolled in the study and performed a 16-week eccentric calf-muscle exercise program. Outcome measurements were the validated Victorian Institute of Sports Assessment-Achilles (VISA-A) questionnaire and MRI parameters at baseline and after 24 weeks. Tendon volume, tendon maximum cross-sectional area (CSA), tendon maximum anterior-posterior diameter (AP) and signal intensity (SI) were evaluated. Intraclass correlation coefficients (ICCs) and minimum detectable changes (MDCs) for each parameter were established in a reliability analysis. Complete follow-up was accomplished in 20 patients. The average VISA-A scores rose significantly by 12.3 points. The reliability was fair-good for all MRI-parameters with ICCs greater than 0.50. Average tendon volume and CSA declined significantly by 0.28 cubic centimeters and 4.52 square millimeters, respectively. Additional MRI parameters did not change significantly. None of the baseline MRI parameters were bivariately associated with VISA-A change following 24 weeks. The rise in MRI SI over that period was positively correlated with the VISA-A score improvement.

Practice Management

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Many captive insurance companies are being audited across the United States for being abused by physicians for tax benefits and to insure them against "sham risk." Attorney Jay Adkisson warns many so-called "rescue plans" from these firms are meant to be distractions. His advice to physicians is to be cautious, solicit second opinions and avoid temptation by the higher premium levels available this year unless they have real risks and a solid team to operate their captive in a legally compliant manner. Among the seasonal risks worth considering are those relating to physicians' status as an employer. Specifics include avoidance of discriminating in how they allot vacation time requests among employees, having a published policy and adhering to that policy. Another piece of advice is to beware of bias in how they provide vacation pay and benefits. Physicians should include a specific plan in their employment policy manual and apply uniform enforcement. They should also be wary of employee classification risk and their treatment of any employees compensated as contractors in relation to their vacation time requests and compensation. Such actions have legal implications if they ever become an issue. Finally, the dress code is worth consideration. Physicians should permit employees to vary from their official policy to account for holidays, heat waves and more while ensuring it remains appropriate and that all staff comport themselves professionally.


Insurance firms are increasingly emphasizing value-based plans to bring consumer spending into line with the value generated by a service or drug, but drug manufacturers are hurting these efforts with the issuance of "copayment coupons." Experts note with a coupon, an expensive drug may not entail any costs to the patient. Insurers attempt to encourage patients to opt for lower-cost medications via formularies, where patients have higher copayments for higher-priced medications and lower copayments for lower-priced ones. This has helped insurers boost the usage of less expensive drugs, mostly generics. Processing drug coupons means additional work for the pharmacist, who gets a small extra fee from the third-party coupon vendor, on behalf of the drug company. This incentivizes the pharmacist to process coupons. Internal medicine practitioner Martin Derrow says he typically writes prescriptions for generic medications, which work well overall for patients with chronic disorders. As drug makers usually issue coupons for expensive, newer drugs, Derrow says he explains to patients bearing coupons that the generic may be the better general choice. He says since coupon use leads to higher premiums in the long term, he tells patients who do well on low-cost, high-value medications to use them instead of costly new drugs.


Testing older physicians for mental and physical ability is growing more common. Nearly a fourth of physicians in America are 65 or older, and 40 percent of these are actively involved in patient care, according to the American Medical Association (AMA). Experts at AMA have suggested that they be screened lest they pose a risk to patients. An AMA working group is considering guidelines. Concern over older physicians' mental states—and whether it is safe for them to care for patients—has prompted a number of institutions, from Stanford Health Care in Palo Alto, Calif., to Driscoll Children's Hospital in Corpus Christi, Texas, to the University of Virginia Health System, to adopt age-related physician policies in recent years. The goal is to spot problems, in particular signs of cognitive decline or dementia. Now, as more institutions like Cooper embrace the measures, they are roiling some older doctors and raising questions of fairness, scientific validity and ageism. A group of doctors has been battling Stanford's age-based physician policies for the past five years, contending they are demeaning and discriminatory. Studies have found that, on average, knowledge declines over time, but it varies significantly among individual physicians, AMA says. Hospitals say they are trying to be sensitive. “We are not making our doctors go through this big elaborate psychological evaluation,” says Dr. Karl Serrao, who helped develop a screening program for older doctors at Driscoll Children's Hospital.

Health Policy and Reimbursement

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The House has voted to limit damages from medical malpractice lawsuits by capping emotional suffering and other noneconomic harms to $250,000. The legislation would also set up a three-year statute of limitations following an injury or one year following discovery of an injury. Advocates say the bill would help reduce healthcare costs and boost the availability of doctors. The provisions would be applicable to lawsuits where coverage was provided or subsidized by the federal government. State laws also would be preempted, unless they already specify a shorter time period for the statute of limitations or a specific amount of damages that can be awarded in a suit. Full compensation would be accorded to economic losses, such as medical costs and lost wages. The Congressional Budget Office calculated that the legislation would cut the deficit by about $50 billion over a decade, based on the partial assumption that the measure would lower premiums for medical liability insurance. House Democrats, such as Rep. John Conyers Jr. (Mich.), say the bill would deny full compensation to medical malpractice victims. Conyers notes children, women and low-income people are more likely to be awarded noneconomic damages since they frequently cannot establish economic losses in malpractice suits.


According to the Congressional Budget Office (CBO), the U.S. Senate's proposed healthcare revamp would lead to 22 million additional uninsured Americans and would trim $321 billion from the federal deficit in the next 10 years versus the Affordable Care Act (ACA). Those estimates raise skepticism about the likelihood of the bill's survival as Senate Majority Leader Mitch McConnell (R-Ky.) scrambles to secure votes from GOP lawmakers whose support for the bill is flagging. The American Medical Association also opposes the bill, stating in a letter to Senate leaders that "it will expose low- and middle-income patients to higher costs and greater difficulty in affording care." The bill would mean reduced premiums for many Americans, partly because their plans would encompass fewer benefits. However, lower-income consumers or those with special needs could face substantially higher medical costs. Senate Minority Leader Chuck Schumer (D-N.Y.) said the CBO report "confirms what doctors, patient advocates, Democrats and Republicans have been saying for weeks: Trumpcare will lead to higher costs for less care and will lead to tens of millions of Americans left without health insurance." CBO calculated about 49 million people would be uninsured by 2026 under the Senate bill compared with 28 million under the ACA, mainly due to Medicaid cuts, the termination of a penalty for lacking coverage and smaller subsidies to help low-income people buy insurance.


Senate GOP leaders have delayed a vote on a bill to disband and replace most of the Affordable Care Act (ACA) until after Congress's July 4 recess, due to a lack of enough Republican support. This represents a setback for President Donald Trump and Senate Majority Leader Mitch McConnell (R-Ky.), and Republicans say they must approve the legislation before the August recess. The bill would roll back much of the ACA, including a mandate that most Americans have insurance or pay a penalty. It would deliver smaller tax credits than the ACA's to help people purchase insurance, impose high spending cuts to Medicaid and phase out enhanced federal funding to the 31 states that expanded the program under the current health statute. Among the factors GOP senators cite as contributing to the delay's inevitability was the Congressional Budget Office's estimates that the bill would result in 22 million more uninsured Americans than the ACA over the next decade. Democrats say Republicans' problems reflect the bill's underlying problems, especially its plan to cut health coverage while giving a tax cut to the affluent. Several conservative senators are calling for more deregulation and reduced premiums, while centrists are particularly worried about the Medicaid cuts. Trump pushed for a resolution at a recent White House meeting, claiming the ACA is imploding despite Democrats' arguments to the contrary.

Medicine, Drugs and Devices

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Researchers conducted a prospective, single-arm study to evaluate the safety and effectiveness at 12 and 24 months of Zilver PTX, a paclitaxel-eluting nitinol stent. Between May 2010 and March 2012, 67 patients (78 percent males) with a mean age of 70.1 were treated with Zilver PTX for stenosis or occlusions of the superficial femoral artery (SFA) in one of two centers. Of the patients, 32 were living with diabetes, 14 were active smokers and 11 had chronic renal failure. The average length of lesions was 104 mm, and 26 patients had type C or D lesions according to TASC 2. All patients had successful stent placement. Primary patency, as analyzed using Kaplan-Meier method, was 88 at 12 months and 68 at 24 months. There were five deaths due to systemic comorbidities and three major amputations, all of them in the D group. Among the other patients, differences between D and non-D patients were not significant in terms of wound healing, bipedal stay and spontaneous ambulation. A single patient had fracture and stent migration. In 13 patients living with diabetes, tibial PTA was also observed. Additional treatment was required in six D and one non-D patients. The researchers found that both stent patency and functional results on the basis of both clinical and instrumental tools were similar in D and non-D, indicating a particularly favorable activity of PTX in a subpopulation of people living with diabetes. Although further studies are needed, the use of Zilver PTX is safe and effective in the treatment of SFA lesions, the researchers concluded.


Surgeons canceled some operations at a hospital in Beaver, Pa., after the latest global ransomware attack paralyzed the hospital’s computers. The cyberattack known as Petya, froze computers across two hospitals and satellite locations of Heritage Valley Health System. According to Suzanne Sakson, a spokeswoman for the nonprofit hospital operator, the hospitals and emergency rooms remained open and staff used paper instead of computers. The orthopaedic surgeons in the Association of Specialty Physicians, an independent medical group in Beaver, Pa., canceled more than a dozen elective procedures that were to be performed at Heritage, said Dale Yakish, one of the medical group’s surgeons.


New studies show that the emerging field of digital medicine can improve outcomes in some of the most costly and tough-to-manage categories, such as diabetes, heart disease and lung disease. As a result, a growing number of hospitals and health systems are adopting digital programs that have been studied in clinical trials and can be delivered on a broad scale at low cost with the use of smartphones, wireless devices and sensors. Digital medicine consists of a combination of remote monitoring, behavior modification and personalized intervention overseen by the patients' own doctors. The digital programs are raising patients' confidence that they can manage their health and are providing some hand-holding and nudging when they do not. Experts say the innovations allow doctors to gather data about patient behavior and symptoms and to intervene when patients are not following their regimens or have a flare-up in their disease. Moreover, experts say they enable care teams to deliver continuing and consistent support to change behavior, such as losing weight, taking medications as prescribed and exercising. The push for digital medicine comes as reimbursement for medical care is shifting from fee-for-service arrangements to a focus on delivering quality outcomes at a reasonable cost.