News From ACFAS

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More than 1,800 foot and surgeons are expected to attend our 75^th Anniversary Scientific Conference in Las Vegas next year. Make sure this targeted audience sees your product or service—register as an exhibitor at ACFAS 75.

Held in the Mirage Convention Center February 27–March 2, the Exhibit Hall will feature:

• unopposed viewing time so you can talk one-on-one with attendees and build new client relationships;
• generous exhibit space (100,000+ square feet);
• complimentary lunch each day;
• welcome/networking event on Monday night;
• and much more!

As an exhibitor, you can also sponsor an event or educational grant, advertise in our digital or print media or include your company logo on ACFAS 75 products. Watch for your Exhibitor Prospectus in the mail or view it at acfas.org/asc.
Our popular regional program, ACFAS on the Road: Refining High-Frequency Forefoot Surgery, will be back on the road this fall with three stops scheduled between now and the end of the year. If you’re looking for new approaches to the forefoot procedures you perform most often, then this two-day workshop is for you.

Fire up your learning on Friday night with a surgical complications presentation and case studies, and be sure to bring along your own cases for panel discussion. Then on Saturday, participate in four hands-on sawbones labs interspersed with lectures from expert faculty.

Space is limited—register today at acfas.org/ontheroad. Listen to this month’s podcast for tried and tested strategies for treating lateral ankle instability. Moderator Eric Barp, DPM, FACFAS, and four expert panelists discuss indications, preoperative workup and use of MRI, ancillary studies and stress tests in their treatment plans. Learn the difference between structural and functional ankle instability and rethink your approach to athletic and occupational injuries.

New podcasts are added to ACFAS’ Podcast Library each month—visit acfas.org/e-learning often to hear the latest releases.

Foot and Ankle Surgery

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Supramalleolar osteotomy (SMO) is reported to be effective in the treatment of varus ankle osteoarthritis through load line redistribution. A new study proposes the addition of mesenchymal stem cells (MSCs) to SMO combined with marrow stimulation as a treatment option. In the study of 64 ankles in 62 patients with varus ankle osteoarthritis, 33 ankles underwent arthroscopic marrow stimulation alone (group I), and 31 ankles underwent marrow stimulation with MSCs injection (group II). The group I score improved from 7.2 ± 1.0 to 4.7 ± 1.4 on a mean visual analog scale (VAS) for pain at the final follow-up, and group II improved from 7.3 ± 0.8 to 3.7 ± 1.5 at the follow-up. There was also improvement in group I on the American Orthopaedic Foot and Ankle Society scale. Significant differences in cartilage regeneration were evaluated during second-look arthroscopy between groups (P = 0.015 for medial aspect of the talar dome, P = 0.044 for medial aspect of the tibial plafond, P = 0.005 for articular surface of the medial malleolus), correlating with clinical outcomes in both groups.


Researchers sought to identify prognostic indicators of survival and functional outcome in patients with soft-tissue sarcomas (STS) of the distal lower extremities through a long-term follow-up. Between 1999 and 2014, 120 patients with STS of the foot, ankle and lower leg were treated surgically at a single institution. The median follow-up was 6.3 years. The results reveal that the five-year estimate of the overall survival (OS) rate was 80.0 percent for the entire series. Surgical margins attained at the resection of the primary tumor did not influence OS significantly.


Researchers sought to assess the incidence of tendon entrapments and tendon dislocations associated with ankle and hindfoot fractures in patients studied by multidetector computed tomography (MDCT). A retrospective review was conducted of individuals who had a trauma protocol CT for suspected ankle or hindfoot fractures. This was during a consecutive 41-month time period at a single Level 1 trauma center. Three hundred ninety-eight patients had ankle and/or hindfoot fractures that showed tendon entrapment or dislocation in 64 (16.1 percent) patients. There were 30 (46.9 percent) patients with 40 tendon entrapments, 31 (48.4 percent) patients with 59 tendon dislocations and three (4.7 percent) patients with both tendon entrapment and dislocation. All patients with tendon entrapments were seen with either pilon fractures and/or a combination of posterior, medial or lateral malleolar fractures. The most frequently entrapped tendon was the posterior tibialis tendon in 27 patients (27/30, 90.0 percent). The peroneal tendons were the most frequently dislocated, representing 27 (87.1 percent) of patients with tendon dislocation. All resulted from a talar or calcaneal fracture or subluxation.

Practice Management

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Widespread use of electronic health records (EHRs) in medical practices may be contributing to more errors and malpractice liability, according to a recent report by The Doctors Company, a medical malpractice insurance company. The firm closed almost 100 claims between January 2007 and June 2014 in which EHRs were a contributing factor. The top allegation among the 97 claims was for diagnosis-related errors, followed by medication-related errors, with the wrong medication, the wrong dose or improper medication management given to the patient. From 2007 to 2010, two claims were closed in which the EHR was a contributing factor. In 2013, that number had increased to 28, and 26 such claims were closed in the first two quarters of 2014. Contributing factors in the malpractice claims were both human error and technology issues. The top user factors included data entry errors, health records tracked in multiple formats and stored in multiple places, conversion from paper to digital files, copying and pasting data without modification and lack of EHR training and education.


A practice's relationship with advanced practitioners should be well documented in a written Employment Agreement. Practices should outline defined schedules and expectations for advanced practitioners. Consider how practitioners with a following could compete with the practice during or after their employment, and include confidentiality, non-compete, non-solicitation and non-disparagement provisions. When drafting the contract, review licensing issues, including physician supervision and/or collaboration requirements and prescriptive authority; some states require a copy of the contract to be provided to the licensing authority. Employment Agreements should clearly indicate compensation and policies regarding benefits and bonuses. Many states do not allow advanced practitioners to co-own a practice or to be paid a percentage of the practice's profits. Finally, review the practitioner's malpractice coverage and make sure the contract allows for the cost of the tail commitment to be subtracted from final amounts that may be due to the practitioner upon termination. Practices should tailor contracts to the unique license of the advanced practitioner, reflecting a mutual understanding between parties.


Blogging has advantages for physicians as a marketing tool that resonates with modern Internet-savvy, relationship-based patients. Benefits of blogging to practices include adding marketing value to their website as content can be located by topic, while regular site updates can improve their ranking in search results. Moreover, a medical practice blog offers an online opportunity to demonstrate the credibility of providers in the practice by sharing knowledge on relatable, relevant topics while educating patients. In addition, a blog can give physicians, the practice, and/or staff a "voice" that makes the practice more personable. Setting aside time to blog is initially a factor, but once physicians become acclimated, they find it easier to spend time blogging, and this is reinforced by the benefits it affords to the practice. Still, physicians must remain mindful that blogging must be performed in a way to which they can commit. Consistency and regularity are critical to a successful blog. One strategy for keeping the blog relevant and interesting for the target audience is to have multiple contributors, while another approach is to write several blogs concurrently and schedule them to post throughout the month. Each post should have a disclaimer saying it is in no way intended to replace medical advice from a physician.

Health Policy and Reimbursement

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Data mining of patient medical records kept by the federal government will get a boost by the U.S. Centers for Medicare and Medicaid Services (CMS), following the release of finalized changes to the Qualified Entity Program. The final rule authorizes certain CMS-approved organizations, including for-profit companies, to buy Medicare claims and other federal data at a price that matches the government's cost in processing the data. These “qualified entities” can then combine it with patient data from insurance companies, providers and other sources and then resell that data to those organizations and others, including employers and device makers.


Consumers must be allowed to buy fixed indemnity insurance policies, which do not meet the minimum essential coverage standards required by the Affordable Care Act, according to a ruling by the U.S. Court of Appeals for the District of Columbia Circuit. The Obama administration had previously barred the sale of fixed indemnity policies to people who did not already have coverage that met federal standards. These policies do not cover specific percentages of medical costs and typically provide limited coverage. Plaintiffs in the case, sellers of fixed indemnity insurance, say the limited policies are sometimes the best options for lower-income consumers who do not qualify for Medicaid but cannot afford major medical coverage. The appeals court upheld an earlier decision by the Federal District Court, which said the Obama administration's rule “has no basis in the statutory text it purports to interpret and plainly exceeds the scope of the statute."


The U.S. Office of the National Coordinator for Health Information Technology (ONC) has outlined how it intends to measure interoperability, a requirement detailed in the Medicare Access and CHIP Reauthorization Act. The agency plans to use existing national surveys of clinicians' electronic health record use so as not to add to their reporting burden. ONC detailed its new measurement plan in a July 1 blog post.

Medicine, Drugs and Devices

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U.S. doctors and teaching hospitals got $6.49 billion in research and speaking fees, food and other goods or services from drug, biotechnology and medical device companies in 2015, according to an annual report by the government. The total includes fees such as those provided to medical experts for speaking at industry dinners as well as royalties paid to hospitals whose researchers have invented or helped develop drugs and devices. It also includes food, gifts, hotel rooms, services or entertainment. The 2015 disclosures cover payments to about 618,000 doctors and 1,110 teaching hospitals. Overall, companies made $3.89 billion in payments for research and $2.6 billion for other purposes, according to a summary posted on the website.


Adults with type 2 diabetes and osteoporosis prescribed Forteo therapy saw a lower incidence of vertebral fractures over time, increased bone mineral density (BMD) and reduced back pain, according to new research. The researchers analyzed data from 4,042 adults with osteoporosis at high risk for fracture participating in the Direct Analysis of Nonvertebral Fractures in the Community Experience (DANCE), an open-label, prospective, multicenter observational study. Within the cohort, 291 patients had type 2 diabetes (mean age, 69 years). Analysis included patients receiving at least one dose of teriparatide (20 µg/day subcutaneously). The researchers found no between-group difference in time to new nonvertebral fracture (HR = 1.06; 95 percent CI, 0.49-2.3). Fracture incidence was 3.5 per 100 patient-years during months zero to six for patients with type 2 diabetes vs. 3.2 per 100 patient-years for those without diabetes. From six months to treatment end, fracture incidence was 1.6 per 100 patient-years for those with type 2 diabetes vs. 1.8 per 100 patient-years for those without diabetes. Patients with and without type 2 diabetes showed similar increases in BMD at 18 months at the lumbar spine and total hip; patients with type 2 diabetes showed a greater increase in femoral neck BMD vs. patients without diabetes (0.034 g/cm² vs. 0.004 g/cm²). Both groups experienced a decrease from baseline in mean back pain scores that continued through the end of treatment. There were no new safety findings.


When tolerated, transdermal buprenorphine appears to be an effective treatment for the management of diabetic peripheral neuropathic pain (DPNP), according to a study published in Diabetes Care. For the study, 186 patients with type 1 and type 2 diabetes were analyzed. All had had moderate to severe DPNP for at least six months on maximal tolerated conventional therapy. They were randomly assigned to receive buprenorphine (5 mcg/hour) or placebo patches. The dose was titrated to effect to a maximum of 40 mcg/hour. Many patients did not complete the 12-week study. In all, 37 (39.8 percent) in the buprenorphine group and 24 (25.8 percent) in the placebo group withdrew. Adverse events, in particular nausea and vomiting, were the main reasons for discontinuation in the active treatment group. Inadequate pain control was the main cause in the placebo group. Per-protocol findings showed that a significantly greater proportion of patients in the buprenorphine group (86.3 percent) experienced a 30 percent reduction in pain over baseline than was the case in the placebo group (56.6 percent). In intention-to-treat analysis, there was a trend toward better outcome in the buprenorphine group (51.7 percent versus 41.3 percent), but this did not reach significance.