News From ACFAS

---

Notice anything different? Your weekly College e-newsletter, This Week @ ACFAS, now has a new look! Your go-to source for the latest news from the College and the foot and ankle surgery profession has been redesigned to better align with the ACFAS brand and bring consistency across all College communications. While This Week has undergone a mini-facelift, know that the up-to-date content you count on each week will not change. Enjoy!
Registration for the ACFAS 2015 Annual Scientific Conference is now open! Join your fellow colleagues February 19-22, 2015, at the Phoenix Convention Center for: in-depth scientific sessions; intensive hands-on workshops; award-winning research; practical learning in The HUB (sponsored by PICA); the ACFAS Job Fair and an expansive Exhibit Hall; fabulous special events and networking opportunities; and much more! Plus, be among the first to register at acfas.org/phoenix and receive our special early bird rate.

Watch your mailbox for the official ACFAS 2015 program book or visit acfas.org/phoenix for full details on what’s in store for you in Phoenix! After careful review and consideration of applicants to serve on the ACFAS Board of Directors, the Nominating Committee recommends these five Fellows for three positions in the upcoming electronic election:

• Christopher F. Hyer, DPM, FACFAS (Incumbent)
• Jeffrey R. Baker, DPM, FACFAS
• John T. Marcoux, DPM, FACFAS
• Scott C. Nelson, DPM, FACFAS
• Randal Wraalstad, DPM, FACFAS

Two three-year terms and one one-year term will be filled by election. Candidate profiles and position statements will be posted on acfas.org/nominations by November 14. The ballot order is prescribed in the bylaws, and eligible voters may cast one, two or three votes on their ballot. Regular member classes eligible to vote are Fellows, Associates, Emeritus (formerly Senior) and Life Members. Individuals who intend to nominate by petition must notify ACFAS by October 30, and petitions are due no later than November 22.

ACFAS will use online e-voting from December 7 to January 6. All eligible voters will receive an email with special ID information and a link to the election website no later than December 6. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot. Eligible voters without an email address will receive paper instructions on how to log in to the election website and vote. There will be no paper ballots.

The 2014 Nominating Committee included Jordan P. Grossman, DPM, Chair; Thomas S. Roukis, DPM; Bruce A. Scudday, DPM; Gregory P. Still, DPM; James L. Thomas, DPM; Eric G. Walter, DPM, and Julie A. Wieger, DPM. The U.S. Centers for Disease Control and Prevention (CDC) has established a webpage with information about the Ebola outbreak. In addition, the American Medical Association (AMA) has set up an Ebola resource center. Both sites are updated with relevant information as it becomes available.

Foot and Ankle Surgery

---

A recent review of 17 studies has found that intramedullary fixation, a minimally invasive technique for treating unstable distal fibular fractures, which was introduced due to concerns about complications associated with current standard of care open reduction and internal fixation (ORIF), can produce excellent results. After reviewing the studies, which involved 1,008 distal fibular fracture patients treated with intramedullary fixation using compression screws or nails, the study's authors found that the average union rate in patients who were treated with compression screws or nails was 98.5 percent. The average union rates in patients treated with unlocked intramedullary nailing and locked intramedullary nailing were 100 percent and 98 percent, respectively. In addition, as many as 91.3 percent of all patients reported functional outcomes as being good or excellent. Good or excellent functional outcomes were reported in up to 92 percent of patients treated with unlocked intramedullary nailing and in over 50 percent of those treated with locked intramedullary nailing. The average complication rate in all the studies was 10.3 percent, with the most common complications being fibular shortening and implant-related problems that required metalwork to be removed. Although the study's authors said these results are similar to those seen in patients treated with modern plating techniques, they noted insufficient evidence shows that intramedullary fixation produces better clinical and functional outcomes compared to standard techniques.


A technique that combines intraoperative fluoroscopy and subtalar arthroscopy could be an effective treatment option for certain types of displaced intra-articular calcaneal fractures, a new study has found. The study involved 13 patients, all of whom were followed up with after at least 13 months. At final follow-up, the study's authors calculated three functional outcome scores--the American Orthopaedic Foot and Ankle Society ankle-hindfoot score, the Foot Function Index and the Calcaneal Fracture Scoring System--for nine patients and determined that these scores were similar to those seen in patients who had been treated with percutaneous methods in other studies. Another outcome measure the study's authors examined was the Bohler angle, which improved by an average of 18.3 degrees with subsidence of 1.7 degrees. In addition, post-operative computed tomography (CT) scans performed on eight patients showed that maximal residual articular incongruity was 2 mm or less in 87.5 percent of the cases. The study also found that patients who underwent this procedure were at a lower risk of wound complications compared to patients who were treated with percutaneous methods. However, the authors cautioned that the technique should be combined with careful patient selection and that additional large studies need to be performed to determine the technique's potential benefits.

Practice Management

---

Conflict between employees at physicians' practices could potentially create legal issues, so practice managers should be sure to do everything they can to prevent disagreements and arguments from occurring in the first place, experts say. One way practices can reduce the likelihood of conflict is by having a no-tolerance policy in effect that not only says conflict will not be tolerated but also states that gossip and other behaviors that lead to conflict are unacceptable, says mediator Vivian Scott. Employees should also be trained to recognize and respect their colleagues' different personalties and working styles, says Beth Brascugli De Lima of the human resources consultancy HRM Consulting. Encouraging open communication between employees may also help diffuse any tension that may arise as a result of clashing personalities and different methods for performing certain tasks, experts say. But experts also point out that conflicts may still occur even when these and other steps are taken. If that happens, conflicts should be addressed as soon as possible, particularly when conflicts are rooted in issues that could be violations of government regulations, experts say. Addressing conflicts could involve launching an impartial investigation into the matter that is documented every step of the way. Finally, practice managers may need to fire employees involved in a conflict if their behavior does not improve.


Physicians' practices should follow several steps to keep billing and collection errors to a minimum, writes P.J. Cloud-Moulds of the consultancy Turnaround Medical AR Recovery. The first such step, Cloud-Moulds says, is to ensure all staff members are aware of the practice's policies regarding billing and collections. These policies and procedures should be reviewed by staff members, who should then be asked to sign a form to indicate that they understand them. Another important step in preventing billing and collection errors is to designate an employee to review all delays and denials as a form of monitoring. Staff members should be aware that such monitoring is taking place to ensure transparency and accountability, Cloud-Moulds says. In addition, Cloud-Moulds recommends training staff members who call payers about a patient's benefits to ask whether a decision to pre-deny a charge can be appealed as well as whether the practice can ask for and obtain pre-certification or pre-authorization by demonstrating that a procedure or service is medically necessary. Finally, Cloud-Moulds recommends that practices call patients who have used up their benefits to inform them that their insurer will not be paying for their visit. Doing so avoids a confrontation between such patients and practice staffers in the office and reduces the possibility that a front-office staff member will give the patient an appointment for which the practice is unlikely to be reimbursed, Cloud-Moulds says.

Health Policy and Reimbursement

---

The American Medical Association and several provider groups and health systems have sent a letter to Health and Human Services Secretary Sylvia M. Burwell asking her to address problems with the interoperability of electronic health records (EHRs). The organizations noted in their letter that just 14 percent of doctors can currently transmit health information outside of their organizations electronically. Several factors were blamed for the difficulties in achieving interoperability between EHRs, including "strict" meaningful use (MU) requirements and deadlines set by HHS that have made it difficult to achieve interoperability. The letter's signatories indicated they supported MU of EHR. The letter noted that because of these problems, patient care is not improving as hoped. The organizations included several recommendations they believe will address the issues they raised and will improve the meaningful use process, including streamlining and focusing meaningful use certification requirements on interoperability, quality measure reporting, privacy and security. In addition, the organizations recommended replacing certification mandates with a flexible and scalable standard based on open system architectural features to allow data to be sent to and from healthcare organizations more easily.


The American Medical Association (AMA) sent a letter to the Centers for Medicare and Medicaid Services (CMS) and the Office of the National Coordinator (ONC) for Health IT containing several recommendations for changing the Meaningful Use (MU) program to improve the functionality of electronic health records (EHRs). The organization noted in its letter that thousands of physicians have chosen not to participate in MU and that this could be rectified by adopting a more flexible approach for meeting the program's requirements. AMA also called for quality measurements to be better aligned. This would include reducing the amount of reporting physicians need to perform and ensuring they are not charged overlapping penalties. These unnecessary penalties make it difficult for physicians to participate in new payment and delivery models that could help improve the quality of care given to patients, AMA President Robert M. Wah, MD, said in a separate statement. EHR certification should also be changed to focus on interoperability and other important issues, AMA said. These recommendations come as CMS and ONC prepare to release the proposed rule for Meaningful Use Stage 3.


Data released by the Centers for Medicare and Medicaid Services (CMS) shows that the Pioneer accountable care organization (ACO) program has had a mixed record when it comes to saving providers money. The program began in 2012 with 32 participating providers, half of whom saved money that year while the other half achieved no savings or saw their costs rise, the data shows. On one end of the spectrum was an ACO that saved roughly $23 million, or 7 percent of its expected expenses based on benchmarks in 2012, while on the other end was another ACO that lost more than $9.3 million. But average spending in 2012 was roughly $20 less per Medicare beneficiary per month compared to if the ACO was not taking part in the program, according to CMS. As for 2013, 14 of the ACOs that released results for that year said they achieved savings while six said they lost money. These mixed results come as providers are leaving the program, with three withdrawing in September alone. Nineteen providers now participate.

Medicine, Drugs and Devices

---

A recent study sought to at least partially settle the controversy over the effectiveness of hyperbaric oxygen therapy (HBOT) in treating certain diabetic foot wounds by examining the relationship between the presence of certain comorbidities and the procedure's effectiveness. The study involved 117 patients with 126 diabetic foot wounds that ranged from 3 to 5 on the Wagner Grading System. All of the patients were asked about certain comorbidities and were monitored for one year after undergoing HBOT. The study's authors found that the effectiveness of HBOT was hampered in patients with a history of coronary heart disease, stroke and non-proliferative or proliferative retinopathy. Peripheral arterial disease (PAD) at the femoral arterial level was found to have a significant negative impact on HBOT outcomes that should first be considered for surgery, although PAD below the knee did not impact the effectiveness of HBOT.


A new study features the first clinical results seen in calcaneal fracture patients treated with new "bionic" plates, which were developed to prevent implant failure during plate osteosynthesis. The study's authors performed biomechanical tests on six of these bionic plates, which are designed to have the same trabecular orientation as the calcaneus, and compared the results of these tests to those performed on six standard calcaneal plates. Ten patients were treated with the bionic plates and were followed up with after 12 months. None of the patients treated with the bionic plates experienced implant failure or loss of reduction, nor did they experience major complications. The study's authors also found that fatigue life was 68 percent higher in the bionic plates than it was in the standard plates, while load to failure was 100 percent higher in the bionic plates. The bionic plates also displayed significantly reduced displacement under load compared to standard plates. The average American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, meanwhile, was 79. The study concluded that these results are promising, but they must be confirmed by larger clinical trials.


A recent study sought to add to the body of evidence regarding how well Kinesio tape, which is increasingly used to prevent and treat injuries to ankles and other joints, improves joint stability and neuromuscular control. The study's 22 participants, none of whom had a history of ankle injuries, had electromyography sensors placed on their lower leg muscles and were asked to jump from a 35cm platform onto force plates. This was done three times: before the Kinesio tape was applied, immediately after the tape was applied and following 24 hours of continued use of the tape. The study's authors found that the tape decreased muscle activity in the tibialis anterior and peroneus longus muscles. No changes in amplitude or timing of ground reaction forces were observed during each of the three tests. The study's authors noted that this is contrary to the proposed mechanisms of Kinesio tape.