News From ACFAS

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A step forward for wound care, the Centers of Medicare and Medicaid Services (CMS) Physician Compare website has been updated to include three wound care-specific quality measures:

• Adequate off-loading of diabetic foot ulcer at each treatment visit.
• Adequate compression of venous leg ulcers at each treatment visit.
• Vascular assessment of patients with chronic leg ulcers.

The website was originally created to help Medicare patients make informed decisions when picking physicians by comparing quality performance data. This publicly available data also incentivizes physicians to improve and maximize their public performance scores.

CMS’ inclusion of wound care-specific quality measures is a result of several years of work and advocacy to increase the Agency’s awareness of chronic wound care. With the summertime update of Physician Compare the site now includes, for the first time, performance data on 12 standard quality measures and 11 specialty-specific measures – three of which are wound care focused.

As foot and ankle surgeons and lower limb experts, including wound care, it’s important to familiarize yourself with this website and understand and practice these standards as it directly affects a patients’ decision on which physician to see. Learn more about this update and its impact from our colleagues at the Alliance of Wound Care Stakeholders, of which ACFAS is a member. Want to learn about all that is happening with the College? Make sure your online profile is up to date! Log into your account at acfas.org to:

• Update your work and personal email addresses, fax number and your work, home or cell numbers.
• Include yourself in the “Find an ACFAS Physician” search tool on FootHealthFacts.org.
• Confirm your preferred mailing address for The Journal of Foot & Ankle Surgery and ACFAS Update.
• Allow your colleagues to contact you through the College’s online membership directory.

Stay connected with your colleagues and the College – let us know as your contact information changes! Need a way to stay ahead of newest research, but don’t have time to sift through countless medical journals? ACFAS Scientific Literature Reviews (SLRs) give you access to a variety of published articles, including case studies, methodology and technical reports, literature reviews, clinical studies and more. These short summaries cover the newest developments in foot and ankle surgery and are compiled monthly just for you!

Visit acfas.org/SLR to read the September SLRs. You can event read past studies with the SLR archive.

Foot and Ankle Surgery

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The study investigated the incidence of tibial neuropathy after talus fractures and computed tomography's (CT) ability to stratify patients at risk for developing post-traumatic neuropathy. In a retrospective analysis, 71 talus fractures and eight contralateral control ankle CTs were reviewed by an observer blinded to clinical information. CT evidence suggestive of tibial neurovascular bundle injury included nerve displacement, perineural fat effacement and bone touching nerve. Twenty-five percent of patients in this cohort had clinical evidence of tibial neuropathy. The association between these CT findings and clinically evident tibial neuropathy was analyzed, indicating high specificity, negative predictive value, moderate accuracy and lower sensitivity associated with the CT findings.

Among the CT findings, nerve displacement and bone touching nerve were associated with tibial neuropathy. CT findings were associated with hospital length of stay, while the presence of tibial neuropathy and a nerve recovery were not. Researchers conclude that tibial neuropathy occurs following talus fractures, and CT findings may reduce the number of patients requiring close neurological follow-up.


The study investigated the incidence, mean age of appearance and fusion and fusion rate of ossicles of the talus (os trigonum) in a large cohort of pediatric patients. The study conducted a retrospective review of 2620 radiographs from 261 healthy white pediatric patients (ranging in age from 0.25 to seven years at enrollment). Radiographs were examined to determine the incidence of os trigonum, the age of appearance and, if present, the age of fusion. Skeletal maturity was graded based on ossification pattern of the calcaneal apophysis. Radiographic evidence of os trigonum was present in 18 percent of patients, with no difference in incidence between females and males, though os trigonum was found to appear at a significantly younger age in females than in males.

Overall, 70 percent of subjects with os trigonum achieved fusion by age 17, with no significant difference between sexes. Grading of skeletal maturity at the time of fusion showed that both male and female subjects underwent fusion on average between calcaneal stages two and three. The study confirms a relatively large prevalence of os trigonum in a random pediatric population and clarifies both the average age of onset and high rate of fusion at a narrow range of skeletal maturity.


Standard foot and ankle radiographs have long been studied and analyzed to provide a common framework for understanding the relationships of the foot and ankle. The authors describe eight angles measured on 100 patients by up to 18 observers, including four attending physicians, two students and 12 residents. The study validates the previously documented normal angles with a larger observer group and a greater number of analyzed angles. The study also reveals that the tibio-second metatarsal angle on the calcaneal axial view is not a reliable radiographic angle for evaluating foot and ankle deformity. Moreover, intraclass correlation coefficients displayed variability in measurements based on level of training, with residents being the most accurate, followed by attending physicians and finally students.

Practice Management

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Change in the healthcare industry are helping to redefine the examination table as a clinical hub where diagnostics, patient engagement and treatment intersect to improve the quality of care delivered. A height-adjustable examination chair, especially one that combines both clinical and comfort-related design elements, can keep physicians safe while making high-quality care more accessible for patients with mobility limitations. Fixed-height, box-type tables can be an obstacle to care as the standard 32-inch height is nearly double that of a common wheelchair seat, making it impossible for some patients to transfer onto the table without assistance. Fixed-height examination tables can present problems for patients and physicians.

A 2013 survey in the Annals of Internal Medicine finds that 54 percent of practice administrators acknowledged that providers often skipped parts of an exam when encountering a barrier to examining patients with disabilities. For providers, assisting a dependent patient onto a fixed-height examination table is difficult and demanding. Caregivers reported significantly lower perceived physical exertion when performing this task with a height adjustable examination chair.


According to a recent review of studies, published in The Lancet Planetary Health, nutrition is insufficiently incorporated into medial education. The review looked at 24 studies conducted between 2012 and 2018 that assessed recently-graduated or current medical students for their nutrition knowledge; their attitudes, skills and/or confidence in nutrition or nutrition counselling; the quality of nutrition curriculum initiatives for medical students; or their perceptions of nutrition education. Students uniformly reported a lack of required nutrition knowledge, which was confirmed through testing. One study indicated that when nutrition knowledge was assessed in a test, half of medical students scored below the pass rate.

The studies consistently found that medical students wanted to develop their skills in nutrition care, but perceived that their education did not equip them to do so. Most corrective initiatives were not comprehensive, but initiatives that were innovative and well-integrated into curricula showed short-term and long-term benefits for patients and health systems. Given that poor nutrition is a leading cause of death, the authors say the results of the study are alarming. They recommend compulsory nutrition education for all medical students; the establishment of a global benchmark on the required level of nutrition knowledge for future doctors; and more funding to put towards developing new ways to teach nutrition in medical school.


An efficient electronic health record (EHR) system is critical to effective and timely patient care. Physicians need an EHR that streamlines their clinical workflow by granting easy access to electronic patient data. Experts say that medical practices should start by improving EHR usability, which means working with doctors to understand how data can be presented more intuitively. Health IT vendors and provider organizations must help facilitate that feedback. A recent study indicates that nearly 60 percent of physicians say they had no input in the system they are currently using for patient care. Physicians, meanwhile, should keep in mind that good EHR design does not necessarily mean simply copying the familiar paper processes, as this thinking has led to many of the problems associated with EHRs today.

Health Policy and Reimbursement

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In a survey of 2,500 patients conducted by TransUnion Healthcare, 62 percent of respondents said that knowing their out-of-pocket expenses ahead of service impacts the likelihood that they will pursue care. Forty-nine percent of respondents said that having clear information on expected out-of-pocket costs before receiving treatment impacts their decision to use a healthcare provider, and 75 percent of patients use healthcare provider or payer websites to research health costs. Sixty-five percent of patients said they would be more willing to make at least a partial payment if they got an estimate at the time of their healthcare service.

Moreover, 40 percent of respondents said the state of the economy affects how often they seek medical care, and one in four patients said that news of a weakening economy prompts them to use their existing health insurance for a check up or treatment they may have been delaying. TransUnion noted that although 80 percent of patients were satisfied with the care they received, only 67 percent were satisfied with their financial experience. The survey reinforces that health systems need to focus on price transparency and shows that consumers are increasingly making healthcare decisions based on cost.


A Milliman study commissioned by the National Osteoporosis Foundation (NOF) estimates that osteoporosis and subsequent bone fractures exceeded $6.3 billion in additional costs to Medicare in 2015. Two million Medicare beneficiaries suffered 2.3 million fractures in 2015, yet only 9 percent of enrollees were screened for osteoporosis within half a year of the initial fracture. In the year-long period following osteoporotic fracture, the direct medical cost topped $21,800 per beneficiary, more than double the costs incurred in the 12-month period prior to the injury.

Although more than 40 percent of beneficiaries who suffered an osteoporotic fracture were hospitalized within a week, nearly 20 percent died within 12 months of undergoing an additional fracture. Last year, the total yearly cost of providing care associated with osteoporotic fractures was $57 billion, which is expected to reach $95 billion in 2040. NOF CEO Elizabeth Thompson criticized the healthcare system for failing millions of osteoporosis sufferers, noting proven methods can curb its impact, including "state-of-the-art bone density testing to identify those who are at risk of bone fractures." She also cited drug treatments approved by the U.S. Food and Drug Administration that can help reduce spine and hip fractures and cut repeat fractures.

Medicine, Drugs and Devices

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The surging price of insulin is not the only barrier that people with Type 1 diabetes face when getting the medical supplies they need. Managing Type 1 diabetes requires more than just insulin, and insurance restrictions have kept many patients from accessing other essential medical supplies. One such supply is the Dexcom continuous glucose monitor, which lets patients continuously monitor and be aware of their blood sugar levels, alerting them when their glucose is dangerously low. The newest version of the monitor has three parts, and each part requires a "prior authorization" from an insurer before it is prescribed, leading to a great deal of arbitrary denials. Prior authorizations have become a major concern for physicians across the U.S. healthcare system.

In a December 2018 survey of 1,000 physicians, conducted by the American Medical Association, 91 percent of respondents said that prior authorizations "have a negative impact on patient clinical outcomes." An additional 75 percent said the requirements "can at least sometimes lead to patients abandoning a recommended course of treatment," and 28 percent said the prior authorization process had "led to serious or life-threatening events" for their patients. The American Association of Clinical Endocrinologists says that specialists should not have to fill out prior authorizations for endocrine treatments, including treatments for diabetes. Insurers say that prior authorizations are necessary, but they have acknowledged that the system needs improvement. In January 2018, the American Medical Association signed a consensus agreement with a group of insurers identifying five areas for improvement in the prior authorization process.


A study by researchers at Rutgers University finds that U.S. physicians are increasingly ordering medications for children that are not approved by the U.S. Food and Drug Administration. The study analyzed data collected from 2006 to 2015 in the U.S. Centers for Disease Control and Prevention's National Ambulatory Medical Care Surveys. It found that doctors ordered one or more off-label systemic drugs in 19 percent of the two billion pediatric office visits analyzed, most frequently for common conditions such as asthma or mental health disorders. The study also found that, among visits with at least one ordered drug, the rates of ordering off-label increased from 42 percent in 2006 to 47 percent by 2015. Rates of off-label drug orders were higher for girls and for children with chronic conditions, and specialists ordered them more commonly than general practitioners. The most frequently ordered off-label drugs were antihistamines, antibiotics and antidepressants.


A crackdown on opioid medications has forced some doctors to taper the drugs prescribed to their patients, often against their will. This comes as pain management has become a nationwide discussion after a large number of Americans have died because of opioid related overdoses. However, millions of Americans rely on opioids to relieve the chronic pain they deal with on a daily basis. These patients have expressed displeasure and fear over how the situation has affected them. Some have had their medications tapered over a period of time, while others have been forced to cut back at a swifter pace. Experts say there is no easy way to address the problem. Long-term use of opioids creates dependency and tapering off painkillers can result in extreme pain and withdrawals.


According to findings published in the Journal of NeuroEngineering and Rehabilitation, a new therapeutic shoe designed to improve stroke rehabilitation is showing promise. The iStride Device addresses gait asymmetry in stroke patients by making it harder to walk on the good leg, thereby strengthening the stroke-impacted leg and allowing it to become more symmetrical. A trial tested the device on six people between the ages of 57 and 74 who had suffered a cerebral stroke at least one year before the study, all of whom had gait asymmetry.

Each received twelve, 30-minute gait training sessions for four weeks, and the patients' gait symmetry and functional walking were measured using the ProtoKinetics Zeno Walkway system. All participants improved their gait's symmetry and speed, and four improved the percentage of time spent in a gait cycle with both feet simultaneously planted on the ground, known as double limb support. Two of the three participants who were previously limited to walking in their homes could successfully navigate public venues after the study.