News From ACFAS

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The deadline to submit applications to volunteer for an ACFAS committee for the 2014-15 year is this Friday, November 29.

By volunteering to be a part of one of the 11 ACFAS committees, you are taking advantage of the opportunity to get involved in your College and to grow professionally as a foot and ankle surgeon.

To apply, visit acfas.org/volunteer to read the ACFAS Volunteer Requirements and to complete the 2014 Volunteer Application. Remember, all applications must be sent to ACFAS Headquarters no later than November 29. Looking for a new practitioner for your practice? Employers can take advantage of the new ACFAS Job Fair at the Annual Scientific Conference in Orlando by posting open positions on bulletin boards at the fair, and also online via the PodiatryCareers.org career center. The PodiatryCareers.org online tool also allows employers and potential employees to connect and potentially meet for interviews during the conference.

Plan ahead and consider posting your open position at the ACFAS Job Fair -- more details on registration will be made available soon at acfas.org. ACFAS' Annual Scientific Conference attracts the best and brightest speakers and attendees – use the job fair to attract them to your practice, as well!

Foot and Ankle Surgery

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A recent study examined functional outcomes in patients who underwent surgery to treat trimalleolar fractures. Researchers examined 31 patients one year after undergoing the surgery, and found that 11 still had residual pain. Another 13 patients had persistent ankle stiffness, while 10 experienced swelling. Only four of the 12 patients who had participated in sports before their operation were able to do so afterward, while three were no longer able to take part in sports. Researchers found that larger posterior malleolar fragment size is related to poorer functional outcomes in patients who underwent surgery to treat trimalleolar fractures.


A recent study compared the effectiveness, tolerability, and costs of clostridial collagenase ointment (CCO) debridement to that of debridement using saline moistened gauze (SMG) with selective sharp debridement in treating diabetic foot ulcers (DFUs). The 48 neuropathic DFU patients who participated in the study were randomized to four weeks of treatment with either CCO or SMG after baseline surgical debridement. The study lasted for a total of 12 weeks. After four weeks of treatment, researchers observed significant improvements in wound assessment scores in both the CCO and SMG groups. However, patients in the CCO group were the only ones to display a statistically significant decrease in mean wound area from baseline at the end of treatment and at the end of follow-up. The CCO group's response rate was also significantly better at the end of follow-up than the response rate seen in the SMG group. Both groups reported similar adverse events. The economic analysis of the two procedures found that direct mean costs per responder were lower in the CCO group than they were in the SMG group in both the physician office and hospital outpatient department settings. Researchers concluded that both CCO and SMG provide similar debridement of DFUs, though CCO is superior to SMG in terms of encouraging healing. Researchers also concluded that CCO is more cost effective than SMG.


It may be safe to perform early primary closure on carefully selected chronic foot wounds following lower extremity revascularization, a new study has found. The study also noted that performing early primary closure on these wounds can help avoid ongoing soft tissue infection. The study examined seven patients who had undergone lower extremity revascularization and primary wound closure--including toe/forefoot amputations, skin grafting, and the use of local flaps--during the same hospital visit. These patients' wounds were primarily closed at a median of six days following revascularization. Complete healing was achieved in four patients following primary closure, though one patient had to undergo wound care to achieve secondary healing. The limb-salvage rate was 86 percent at six months. Two patients had to undergo major amputation.

Practice Management

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A growing number of hospitals across the U.S. are using telepresence robots to give their patients access to medical specialists who may not be available otherwise. According to InTouch, a company that makes telemedicine devices, almost 1,000 hospitals in the U.S. and overseas are now using its products. The growing use of telepresence robots is especially pronounced in rural areas where doctors are few and far between. However, telepresence robots allow specialists who are located far away to visit patients in hospitals, provide them with a diagnosis, and offer medical advice in the event of an emergency. Such visits begin when a doctor remotely logs in to a robot located at a particular hospital using a computer or an iPad. The robot then maneuvers itself to the patient's room. The robot's camera and microphone allow the doctor to see and hear the patient, while the onboard TV screen and speakers make it possible for the patient to see and hear the specialist. Doctors can also access patients' clinical data and medical images. Any actions that the robot cannot perform are carried out by an onsite nurse or medical assistant. Doctors who have used such robots say they allow them to feel like they are in the hospital room with a patient, and that these interactions are the next best thing to seeing a patient in person.

Health Policy and Reimbursement

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There are concerns that the reimbursement rates being offered to physicians' practices by health insurance plans sold on online marketplaces may be too low to encourage doctors to participate in the plans. Although a survey of doctors by the Medical Group Management Association in September found that many doctors had not been informed of the fees they would be paid for treating patients covered by a plan offered through an exchange, 37 percent of those who had been told said the rates were lower than Medicare. Another 18 percent said the rates were lower than Medicaid rates. The new lower reimbursement rates being offered by some insurance companies are designed to keep costs low for consumers purchasing plans through the online marketplaces. However, some doctors and experts say physicians could opt to leave the plans when they hear about the new rates. That could leave consumers with online marketplace plans with fewer doctors to choose from. A Department of Health and Human Services spokeswoman addressed those concerns, saying qualified health plans are required to offer customers a "sufficient" network of providers.


Insurance companies and several states are taking steps to bypass Healthcare.gov in case the problem-plagued federal health insurance exchange is still not working as intended by the end of this month. The deadline is important because millions of consumers may not have health insurance next year if Healthcare.gov continues to have major technical problems beyond the end of November. In order to prevent that from happening, insurance companies are hoping to enroll consumers in their plans on their own websites rather than Healthcare.gov. However, there are a number of problems with such an approach, including the fact that insurance companies would need to estimate tax subsidies themselves in order to avoid having to deal with Healthcare.gov altogether. A spokesman for America's Health Insurance Plans said the industry does not have the ability to make such estimates, while others have said that insurers will open themselves up to potential risks if they are not able to accurately estimate subsidies. Another drawback to directly enrolling consumers on insurance company websites is that consumers would be unable to make direct comparisons between two companies' plans, as they can do on Healthcare.gov. Meanwhile, Indiana has decided to extend coverage provided to sick consumers through "high-risk" pools beyond the planned Jan. 1, 2014 phase-out date. Other states are considering similar moves.


The U.S. House held two separate hearings on Nov. 19, both focusing on the ongoing problems with Healthcare.gov. Testifying at a House Energy and Commerce subcommittee was Centers for Medicare and Medicaid Services (CMS) Deputy Chief Information Officer Henry Chao, who said roughly 30 percent of Healthcare.gov is still in the process of being developed. Some of the functions that Chao said have yet to be completed are "back office" processes, including payment systems used to transfer federal subsidies for certain consumers to health insurance companies. Chao also said that while efforts to correct the problems with Healthcare.gov are on the "right track," he did not think it would be prudent to completely guarantee that the site would be working for the majority of Americans by the end of this month, as President Obama has promised. Nevertheless, work is taking place around-the-clock on Healthcare.gov's remaining "functional defects," Chao said. Meanwhile, a separate House hearing on Nov. 19 focused on a report by a cybersecurity firm that said Healthcare.gov needs to be completely redesigned and relaunched due to vulnerabilities that could be exploited by hackers to steal sensitive consumer information. Chao addressed the report as well, saying Healthcare.gov features several layers of security.


The House Energy and Commerce Committee released a report on Nov. 18 noting that senior Obama administration officials were aware of potential problems with Healthcare.gov as early as March. The report cited PowerPoint presentations given to Health and Human Services (HHS) Secretary Kathleen Sebelius and others at HHS and the White House during four different sessions from March 28 to April 8. The presentations, which were given by consultants from McKinsey & Co., noted that the shortened testing period for Healthcare.gov could make it difficult for the administration to correct problems with the health insurance exchange after it was launched on Oct. 1. The presentations warned of other problems as well, including a lack of comprehensive testing and the fact that many of the website's functions were dependent on contractors. Consultants from McKinsey & Co. concluded that the administration should not take risks to meet the deadlines for the Healthcare.gov rollout. The Energy and Commerce Committee used the report to criticize Sebelius for telling lawmakers earlier this year that Healthcare.gov was on track even though she had seen the McKinsey & Co. presentations two weeks prior to her testimony. The Centers for Medicare and Medicaid Services has said that steps were taken to address the potential risks that were highlighted in the presentations.

Medicine, Drugs and Devices

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A new study has concluded that dual-energy computed tomography (CT) imaging is useful in detecting the presence and analyzing the features of urate deposits in the feet of gout patients. Researchers performed CT scans on both the feet of 80 gout patients, which led to the discovery of 333 areas of urate deposition. Sixty-one of the urate deposits were located in the calcaneal bone, making that location the most commonly affected site in the patients who were studied. Other commonly affected areas of the body included the distal area of the first toe and the first metatarsophalangeal joint (MPJ). In addition to determining which areas of the body were typically affected by urate deposits, researchers also sought to establish links between the locations of those deposits and different types of arthritis attacks. For example, researchers discovered a relationship between urate deposits in the flexor pollicis longus muscle tendon as well as solitary and punctate dispositions and acute arthritis attacks in the first MPJ. Urate deposits located near the ankle, including the flexor tendon adjacent to the inferior tibia, were associated with arthritis attacks in the ankle.


Researchers have published data from the open-label extension (OLE) of the PREMIER trial, which examined the long-term safety and effectiveness of using adalimumab and/or methotrexate (MTX) in treating patients with aggressive early-stage rheumatoid arthritis (RA). Patients who participated in the study were randomized to receive blinded adalimumab and MTX, adalimumab alone, or MTX alone for two years. Participants who enrolled in the OLE were given adalimumab for up to eight additional years, for a total treatment length of as much as 10 years. Adalimumab was first administered as a monotherapy, though investigators could add MTX to adalimumab if they chose to do so. Researchers found that lack of efficacy was less common in patients who were initially randomized to the adalimumab and MTX group than it was in the adalimumab and MTX monotherapy groups. Patients who were initially randomized to the adalimumab and MTX group also displayed better outcomes, particularly in the prevention of radiographic progression. Researchers concluded that patients who were given intensive therapy of adalimumab and MTX experienced more long-term benefits than did patients who began with two-year adalimumab or MTX monotherapy that lasted as long as 10 years.


A recent study found that there are benefits to using the bioabsorbable Vicryl Rapide suture when suturing skin during surgery for lateral ray polydactyly in children's toes. Researchers found that the 5-0 Vicryl Rapide suture completely disappeared in all nine of the study's participants within three weeks of surgery. There was also no need to remove any residual pieces of the suture. None of the children developed any postoperative complications, such as suture abscess or wound dehiscence. Researchers concluded that there is a low likelihood of postoperative wound dehiscence when using the Vicryl Rapide suture because of the relatively light load that is applied to the lateral toes. In addition, researchers found that there were no cases of elevation of the interdigital space caused by hypertrophic scarring or scar contracture at follow-up exams performed after an average of 24 months. None of the children needed to undergo revision surgery. Finally, researchers found that the use of the Vicryl Rapide suture resulted in the elimination of pain caused by suture removal, no risk of tissue damage, and a reduction in the burden on medical staff.