News From ACFAS

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Master your arthroscopic technique in Advanced Arthroscopy for Foot and Ankle, set for November 7–8 at the Orthopaedic Learning Center in Rosemont, Illinois.

In this hands-on course, you’ll spend more than ten hours in the Cadaver Lab learning the most progressive and effective arthroscopic procedures. Program covers:

• Microfractures
• Posterior Portals
• Allografting
• Tenoscopy and Retrocalcaneal
• Arthroscopic Ankle Stabilization
• Subchondroplasty
• Ankle/Subtalar Joint Arthroscopic Arthrodesis

If you've attended ACFAS’ Foot and Ankle Arthroscopy course or other recognized arthroscopy courses or are a Fellow and have hospital privileges, register now at acfas.org/skills. Space is limited.
The following fellowship meets the minimal requirements to be granted Conditional Status with the College:

CHI Franciscan Health Foot & Ankle Fellowship, Federal Way, WA
Program Director: Byron Hutchinson, DPM, FACFAS
acfas.org/fellowshiphutchinson

All Conditional Status programs are considered for Recognized Status with ACFAS by the Fellowship committee after the first fellow matriculates through the program.

Also, two ACFAS Recognized fellowship programs recently changed program directors:

SSC Sports Medicine Fellowship, Irvine, California
The program director changed from Michael Heaslet, DPM, FACFAS to Austin Hewlett, DPM, FACFAS.
acfas.org/fellowshiphewlett

University Hospitals Richmond Medical Center Fellowship, Concord, Ohio
The program director changed from Jonathan Sharpe, DPM, FACFAS to Mark Mendeszoon, DPM, FACFAS.
acfas.org/fellowshipmendeszoon

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org/fellowshipinitiative to review a complete listing of programs and minimal requirements.

Foot and Ankle Surgery

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A recent study looked to determine the clinical effects of aspiration for ankle fractures. Researchers observed 124 patients and randomized participants to undergo either aspiration or a sham procedure. Pain scores were recorded postoperatively. In the aspiration group, the Numeric Rating Scale pain score fell from 6.5 to 3.7. In the control group, the figure fell from 5.9 to 3.4. No statistically significant difference existed between the groups at any point during the 72-hour period with regard to pain levels. While the pain scores indicated improvement, the results were statistically insignificant.


A recent study analyzed the number and frequency of different terms used to identify complications in total ankle arthroplasty. Researchers looked at 572 unique terms in 117 studies and found that 55.9 percent were used in only a single study. Revision surgery was the most reported, with 86 percent of papers mentioning the event with 115 different terms. Other categories included “additional non-revision surgeries” (74 percent, 93 terms), “loosening/osteolysis” (63, 86), “fractures” (60, 53), “wound problems” (52, 27), “infection” (52, 27) and “implant problems” (50, 57). Researchers concluded that the lack of consistency impedes accurate reporting and interpretation of data. They noted that standardized reporting tools are urgently needed.


A recent study looked to analyze clinical and radiological outcomes following Hintegra total ankle arthroplasty, which depends on the correct tibial and talar alignment to ensure the long-term survival of the total ankle replacement. Sixty-six patients were observed and assessed preoperatively and postoperatively. American Orthopedic Foot & Ankle Society Scores rose from 31.9 to 72.3 at 12 months after surgery. Range of motion increased from 9.5 to 25.4 degrees. The visual analog pain score also dropped from 8.9 to 2.2, and the Tibio-Talar ratio rose as well. The study revealed significant improvements in all clinical and radiological outcomes after Hintegra total ankle arthroplasty.

Practice Management

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For some organizations, the transition to ICD-10 has not been the horror show that experts predicted. Still, implementation has its challenges, and Jennifer Frank notes some early lessons her practice has learned in the wake of the change:

• This is a nail in the coffin for small, independent practices. ICD-10 is so complex that it is hard to imagine any one- or two-doc shop handling everything. Solo practitioners are likely better off transitioning to direct primary care or retiring altogether.
• Day-to-day business has taken a turn for the absurd. The increased specificity of diagnosis codes has its benefits, but there are far too many, and they add nothing but frustration and in-house jokes.
• We are all in this together. Physicians need to unite and stick to the principles that have driven medicine for years. It is important to continue the effort to further the care of patients.
• Nothing is as bad as it seems. ICD-10 has loomed large for years, but it is not impossible. It simply needs to be managed well. Keeping things in perspective can go a long way toward smooth implementation.
• Medicine remains awesome. Remember that caring for patients, building relationships and being the "hero" remain as positives for physicians.

A new survey indicates that 46 percent of physicians and practice managers would consider transitioning to direct pay, concierge care or other membership models in the next three years. Most respondents indicated a desire to spend more time with patients and break away from the insurance payment system. Overall, 81 percent of private practices using direct payment methods noted that they spend an average of 30 to 60 minutes with patients. Most insurance-based practices, on the other hand, only get 15 to 20 minutes. The direct pay method is not without drawbacks: the most-cited challenge was recruiting new patients.


According to Catherine Hambley, PhD, the key to getting the most from your staff is to emphasize what they are doing well. Telling an employee "good job" is nice, but it is not specific and does little to show how much you actually appreciate them. The more specific you can be, the more the positive feedback will affect your staff. Here is a guide for providing effective feedback:

• Look for positive outcomes. Actively look for employees whose actions and behaviors have a positive outcome on you, your patients and the rest of your staff.
• Communicate appreciation. Give genuine feedback and be intentional about taking the time to express appreciation.
• Give on-the-spot kudos. Providing timely feedback in the immediate aftermath of an event often gives the feedback more meaning.
• Be specific, give details. Instead of complimenting your employee, point out the specifics of why you are appreciative of the work in question.
• Be generous with positive observations. Give at least five positives for every corrective or negative communication.
• Express appreciation. Let the employees know how their actions had a positive effect.
• Set up incremental goals. Setting up incremental goals will give you more opportunities to dole out compliments.

Health Policy and Reimbursement

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The Obama administration has issued regulations for the current and final stages of its electronic health record (EHR) incentive program but noted that changes are all but certain to occur in the near future. The rules came paired with a press statement announcing "a 60-day public comment period to gather additional feedback about the EHR incentive programs going forward" that will be used to inform future policy developments. Dr. Patrick Conway, deputy administrator for innovation and quality at the Centers for Medicare and Medicaid Services, said that the rules provide wiggle room for providers who have not yet upgraded to an eligible EHR system, and it allows flexibility for anyone still trying to achieve Stage 2 goals. Not everyone is thrilled about the Stage 3 final rules, including Sen. Lamar Alexander, who has spoken out against the plan because he believes it is being rushed. Alexander, like many critics arguing for a Stage 3 delay until 2017, asked that Stage 2 achievements and failures be assessed first. The American Hospital Association (AHA) called the rules a "mixed bag" and said the release was "much too soon." According to AHA figures, “more than 60 percent of hospitals and about 90 percent of physicians have yet to attest to Stage 2.”


A new report from the Government Accountability Office (GAO) indicates five key factors that are slowing down electronic health record (EHR) interoperability:

1. Insufficiencies in health data standards
2. Variation in state privacy rules
3. Accurately matching patients’ health records
4. Costs associated with interoperability
5. The need for governance and trust among entities

The report also found that changes to the Centers for Medicare and Medicaid Services EHR Incentive Programs would nudge interoperability forward. Representatives from the 18 initiatives GAO reviewed said that meeting the program's requirements often divert attention away from efforts to implement interoperability. Sen. Lamar Alexander, chair of the Senate Health Education Labor and Pensions Committee, noted the report as a reason to hold off on publishing the final rule for Stage 3 of the meaningful use program.


The build-up for ICD-10 was enormous, but so far there have been few instances of chaos relating to implementation. “Aside from a few technical glitches, so far so good,” said Dr. Stephen Michaels, vice president of medical affairs and chief operating officer at MedStar St. Mary's Hospital. Uncertainty still surrounds hospitals across the country, but those challenges likely will not crop up until the end of the month or later as the claims begin to flow. Payers also experienced relative calm once the deadline passed. “We thought the world would end, but everything went pretty smoothly,” said Dr. J. Mario Molina, president and CEO of Medicaid insurer Molina Healthcare. There is still a threat of potential delays if codes are not submitted properly, but most believe it will not be too extensive. Physicians will be in the dark for at least a few weeks, until data is collected and experiences are documented. The deadline reiterated how hard it will be for independent practices to acclimate to ICD-10, although web-based clinical documentation guides are available online for physicians.

Medicine, Drugs and Devices

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The onset of telemedicine has made telesurgery possible, but concerns still exist about adequate bandwidth and feedback delays that are hampering implementation. Dr. Roger Smith of the Florida Hospital Nicholson Center believes that these issues must be solved because telesurgery can benefit anyone, from members of the military to the average consumer at home. Smith also says the concerns are not as harmful as people believe them to be. "Our research is showing that the bandwidth capabilities exist in the current structure of our hospitals and that doctors can safely handle a certain level of delay while performing surgery," he said in an interview. These studies also found that surgeons begin to feel the lag at 300 milliseconds, and recent tests in Florida and Texas delivered latency results of less than 300 ms. While this quality is not uniform across the country, Smith said it is a sign the industry is approaching a "medical quality" Internet. Ultimately, the technology is feasible, and the main barriers are "reliability, social acceptance, insurance and legal liability." Smith believes that more tests need to be done, but the networks that exist today are more than developed enough to properly support telesurgery.


New studies unveiled at the AdvaMed conference revealed that medical devices are a minor player when it comes to rising healthcare costs, leading to renewed calls for a repeal of the device tax built into the Affordable Care Act. The controversial tax amounts to 2.3 percent on medical device sales and was projected to raise $30 billion in ten years, but the studies showed that the tax has hurt research and development spending and has curtailed hiring. Congress is now preparing to tackle the federal budget, so many in the industry believe now is the perfect time to act. “We need to finish the job and close the deal on device tax repeal. It’s a good opportunity right now,” said Stephen Ubl, president and chief executive officer of the AdvaMed.


A panel of venture capitalists at the AdvaMed conference said the medical device industry must adapt to the digital paradigm or risk getting bypassed by companies like IBM, Apple and Samsung. The traditional device industry is in a state of flux because of the advances that large tech companies are making in the field. Apple's HealthKit, Google's life sciences division and IBM Watson's focus on healthcare are all gaining major roles in the fight for device dominance. Currently, the medtech industry focuses on about five percent of the healthcare market while tech companies view it as an asset that consumers will be engaged with 100 percent of the time. "You don’t want to show up with a knife to a gun fight," said Leslie Bottorff, managing director of the healthcare arm of GE Ventures. "The big companies and the small companies need to say, 'What do we need to do to compete with these guys?'" Luckily, money is available in the market to support smaller players if they are willing to work in tandem with digital health. The big step will be for entrepreneurs to step into the digital arena and get involved.