News From ACFAS

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Early birds—discounted registration rates for the 75^th Anniversary Scientific Conference, set for February 27–March 2 at The Mirage in Las Vegas, end December 12. Visit acfas.org/vegas now to take advantage of these special low prices.

Enjoy hundreds of clinical and scientific sessions, intensive hands-on workshops, the latest research from leaders in the profession plus endless opportunities to network with your colleagues. Register before December 12 to get in on the action and save! ACFAS wants to know if you have been performing more elective surgery as 2016 comes to a close. Vote in our new poll at right to let us know and visit acfas.org throughout the month to see up-to-the-minute results. We appreciate your input! Fellow and Associate members, pay your dues by December 31 at acfas.org/paymydues or by mail or fax so your ACFAS membership does not lapse.

Dues reminders for 2017 were both mailed and emailed to you. If you have any questions or require another statement, contact Terry Wilkinson in the Membership Department. After reviewing and scoring a record number of clinical and scientific research grant proposals in November, ACFAS' Research Committee and the College are pleased to announce the funding of five proposals:

The Effect of Rocker Sole Shoes on Gait Following Total Ankle Arthroplasty
Adam Budny, DPM, FACFAS

Percutaneous Kirschner Wire versus Commercial Implant for Hammertoe Repair: A Cost-Effectiveness Analysis
Adam Fleischer, DPM, MPH, FACFAS; Brett J. Waverly, DPM, AACFAS; Rachel H. Albright, DPM; Erin Klein, DPM, MS, FACFAS; Lowell Weil, Jr., DPM, MBA, FACFAS; Lowell S. Weil, Sr., DPM, FACFAS

Cost-Effectiveness Analysis of Primary Arthrodesis versus Open Reduction Internal Fixation for Primarily Ligamentous Lisfranc Injuries
Erin Klein, DPM, MS, FACFAS; Sarah Haller, DPM, AACFAS; Lowell Weil, Jr., DPM, MBA, FACFAS; Lowell S. Weil, Sr., DPM, FACFAS; Adam E. Fleischer, DPM, MPH, FACFAS

Ultrasound-Guided vs. Topography-Guided Injection Therapy for Plantar Fasciitis: A Randomized Controlled Trial
D. Scot Malay, DPM, MSCE, FACFAS; Brittany K. Winfeld, DPM; Eric VonHerbulis, DPM; Paul Niziolek, MD, PhD; Viviane Khoury, MD; Raafae Hussain, DPM; Lauren E. Pruner, DPM; Chrisbel Dafeamekpor, DPM

Printed Three-Dimensional Computerized Tomography Scanned Ankle Fractures as an Educational Instrument
Andrew Meyr, DPM, FACFAS; Todd A. Hasenstein, DPM

Each year, the College awards $40,000 in grant funding to support foot and ankle surgery research. Visit acfas.org/grant to see previous grant winners.

Foot and Ankle Surgery

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Researchers compared spatiotemporal parameters and lower limb and pelvis kinematics during walking in patients with hallux valgus before and after surgery. The experimental group consisted of 17 females with hallux valgus who underwent first metatarsal osteotomy. Prior to surgery, hallux valgus was found to affect spatiotemporal parameters and lower limb and pelvis kinematics during walking, and hallux valgus surgery further increased the differences. After surgery, the walking speed decreased while step time increased for both legs. The maximum ankle plantar flexion of the operated leg during toe-off decreased. The asymmetry in hip and pelvis movements in the frontal plane also persisted.


A clinical trial of first metatarsophalangeal (MTP) joint hemiarthroplasty with a polyvinyl alcohol hydrogel implant demonstrated pain relief and functional outcomes equivalent to first MTP arthrodesis two years after operation. Researchers then evaluated patient outcomes at five years postoperatively. Mean postoperative active MTP natural joint dorsiflexion and peak MTP dorsiflexion were 18.2 and 29.7 degrees, respectively. Pain Visual Analog Scale, Short-Form-36 and Foot and Ankle Ability Measure scores saw statistically significant improvements. No patients experienced changes in implant position, implant loosening or implant wear. One implant was removed due to persistent pain and converted to fusion two years postoperation.


A study examined the association between vitamin D receptor gene FokI polymorphism and diabetic foot ulcers as well as its association with oxidative stress. A total of 212 type 2 diabetes patients with and without diabetic foot ulcer were included in the study. Researchers conducted polymerase chain reaction and restriction fragment length polymorphism analysis. Samples were assessed for thiobarbituric reactive substances (TBARS) and ferric-reducing ability of plasma. There was a significant difference in genotype frequencies of FokI polymorphism in patients with diabetic foot ulcer compared with those without diabetic foot ulcer. Patients carrying the T allele had a significantly higher level of TBARS.

Practice Management

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The coming year will see a greater focus on technological issues, including healthcare data breaches, system failures, hacking and ransomware, according to a recent Black Book poll of healthcare public relations clients. The top concern for 2017 among survey respondents was potential disasters caused by technology-related incidents, followed by financial issues, patient dissatisfaction and nursing staff issues. The survey also found that 92 percent of providers and 90 percent of payers do not have assessments or contingency plans to handle the aftermath of data breaches, malicious activity, thefts and other negative events. Virtually all surveyed hospitals and 71 percent of payer organizations have not integrated mobile technology into their crisis planning. Ransomware attacks in particular are becoming more common, jeopardizing the integrity and availability of sensitive data if the targeted organization does not keep adequate backups. In addition to threatening patient safety and affecting business operations, cybersecurity incidents, such as ransomware, are likely to harm a hospital’s reputation. "Healthcare organizations can take decades to build a regional reputation but only minutes to destroy it," says Black Book’s Doug Brown. "Yet we continue to see examples of how a poorly managed crisis can bring down a hospital and its revenue overnight."


If a physician cannot give traditional, monetary holiday bonuses, staff members can be rewarded for their hard work in other creative ways. Scheduling catering services during late shifts, paying for employees to participate in a local holiday charity run or paying for an employee's gym membership can promote staff wellness and boost morale. Throwing a holiday party for office staff, perhaps in a physician's home, helps build camaraderie outside of work. If the meal is mandatory, hold it during regular business hours so employees are paid to attend. Many practices have a secret Santa or other gift-giving tradition where employees exchange inexpensive gifts. Physicians can also give their staff personalized gifts, such as themed gift baskets, to show their appreciation. If the practice decorates for the holidays, employees should be invited to help. Finally, physicians can make a donation to an employee's favorite charity in his or her name.


When patients are unable to make an appointment without missing work or school, they may be more likely to leave the practice in search of a provider with longer office hours. The Affordable Care Act also promotes initiatives to improve access to primary care in ways that include extended hours. Extending a practice’s hours can have many advantages, such as improved patient access and satisfaction and reduced emergency room visits. The main difficulty with extended hours is staffing, as providers may be reluctant to jeopardize their work-life balance. However, prospective patients have an array of providers to choose from, so offering longer hours can be the difference between gaining and losing patients. Patients often read online reviews of physicians before choosing a provider, so positive reviews of a practice’s convenient, high-quality care will attract others. Keeping the office open longer provides more efficient, cost-effective care to patients who might otherwise turn to emergency rooms or urgent care clinics. Extended hours also help avoid issues that can arise when care occurs at various sites, inhibiting access to patient records.

Health Policy and Reimbursement

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The American Hospital Association (AHA) has issued a letter asking President-elect Donald Trump to cancel Stage 3 of the Meaningful Use program before its mandatory 2018 start date. AHA President and chief executive officer Richard Pollack urged the incoming administration to reduce regulatory and financial burdens on providers who have been required to upgrade their electronic health records (EHRs). “Reducing the administrative complexity of healthcare would save billions of dollars annually and would allow providers to spend more time on patients, not paperwork,” states Pollack. Addressing AHA's request, a U.S. Centers for Medicare and Medicaid Services (CMS) spokesperson said the agency has been receptive to requests for flexibility in the EHR incentive program. CMS this fall eliminated hospital requirements to report on the clinical decision support and computerized provider order entry objectives. The thresholds for a subset of objectives and measures for Stage 2 and Stage 3 also were reduced.


Total spending on healthcare in the U.S. reached $3.2 trillion last year, increasing at the fastest pace since the 2008 recession, the U.S. Department of Health and Human Services (HHS) announced Friday. Total health spending grew 5.8 percent last year, and spending per person increased 5 percent. Health spending accounted for 17.8 percent of the country’s economy in 2015, up from 17.4 the previous year. Federal spending, which accounts for nearly 30 percent of the total figure, increased 21 percent over the past two years, driven by the expansion of Medicaid eligibility and the Affordable Care Act (ACA). HHS report also notes that rapid increases in retail spending on prescription drugs contributed to the growth of national health spending. Prices for existing brand-name medications increased at a double-digit rate for the fourth consecutive year in 2015. ACA was expected to cause a hike in health spending, but the law has cost less than originally projected by the Congressional Budget Office due to the relatively low number of people signing up for subsidized coverage.


The U.S. House of Representatives overwhelmingly passed the 21st Century Cures Act on Wednesday to increase funding for research into cancer and other diseases as well as help combat the prescription drug addictions that have swept the nation. The bill also makes regulatory changes for drugs and medical devices. Passage of the bill in the U.S. Senate appears likely, even though Sen. Elizabeth Warren (D-Mass.) has taken to the floor twice to criticize the bill as a windfall for drug companies, with too few safety provisions. The bill passed with a vote of 392 to 26. It aims to streamline the federal drug regulatory structure to keep up with advances in biotechnology and other forms of medical research. Democrats are unhappy with the way the bill is funded. It authorizes $6.3 billion in money taken from a preventive healthcare fund and other sources, but funding must be appropriated annually. Democrats wanted the funding to be automatic each year. Critics of the bill say it lowers standards for drug and device approvals at the U.S. Food and Drug Administration in exchange for a badly needed funding increase for the U.S. National Institutes of Health.


President-Elect Donald Trump has tapped House Budget Committee Chair Tom Price (R-GA) as secretary of the U.S. Department of Health and Human Services. Price is a former orthopaedic surgeon and one of many Republicans who worked to create an alternative to the Affordable Care Act. Price has also been promoting his Empowering Patients First Act since 2009. He has served in the House since 2005 and has been staunchly against federal funding for abortion. He also opposes federal rules requiring insurance plans to cover contraception without out-of-pocket costs. Trump has also named Seema Verma, a consultant who helped Vice President-Elect Mike Pence negotiate a groundbreaking Medicaid deal with the Obama administration, as the head of the U.S. Centers for Medicare and Medicaid Services.


With a slim Senate majority, congressional Republicans may face an uphill battle striking down the Affordable Care Act (ACA) and replacing it early in President-Elect Donald Trump’s first year in office. An immediate repeal would create a tight deadline for Congress to pass a replacement, potentially creating gaps in coverage. If passed, a replacement system with less federal control would likely take several years to fully implement, according to Lamar Alexander, chair of the Senate Health, Education, Labor and Pensions Committee. To pull off a quick-strike repeal, Republicans would need to pass a budget resolution first for the budget year. Republicans also will face internal disagreements about which mandates of the ACA to keep and whether to defund Planned Parenthood.

Medicine, Drugs and Devices

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The incidence of diabetes mellitus (DM) is higher in patients treated for rheumatoid arthritis (RA), but the effects of different anti-RA medications in the occurrence of DM vary. In a study published in Annals of the Rheumatic Diseases, researchers assessed 13,669 RA patients in the National Data Bank for Rheumatic Diseases. The mean age of the subjects was 58.6 years, and the mean disease duration was 14.4 years. Disease-modifying antirheumatic drugs (DMARDs) were categorized into four groups: methotrexate monotherapy, abatacept with or without synthetic DMARDs, other DMARDs with methotrexate and all other DMARDs without methotrexate. The effects of statin, glucocorticoid and hydroxychloroquine also were studied. During a median 4.6 years of follow-up, 1,139 diabetes cases were observed. The diabetes incidence rate was 1.59 per 100 person-years. Compared with the general adult U.S. population, the standardized incidence ratio of RA patients developing diabetes was 1.37. The adjusted hazard ratios for diabetes were .67 for hydroxychloroquine, 0.52 for abatacept, 1.31 for glucocorticoids and 1.56 for statins. Other synthetic DMARDs and biologic agents were not associated with any change in risk.


Opioids often are prescribed to patients with chronic wounds, but little research has been done to determine the relationship between opioid treatment and wound healing. Prescribing patients opioids for pain management may have an impact on wound outcome, according to a recent study published in Wound Repair and Regeneration. Researchers analyzed 450 patients with chronic wounds and collected data on pain, opioid exposure and size of wounds. A significant link was found between opioid dosage and wound surface area. “More work needs to be done to understand this finding and the possible mechanisms driving it,” says Dr. Victoria Shanmugam, an associate professor of medicine at George Washington University. “We look forward to continuing this research, which may lead to faster healing and improved patient outcomes.”


Virtual reality equipment has become more affordable in recent years, making the technology a more feasible and accessible tool in healthcare. Once costing healthcare organizations more than $30,000 to run a virtual reality system, the equipment now is available at a fraction of that cost. As the technology’s resolution and graphics also improve, virtual reality has the potential to be used for a variety of applications both in clinical settings and healthcare education. Neurosurgeons at the University of California, Los Angeles, have created a virtual reality environment to allow surgeons to practice an operation, improving precision, clinical outcomes and surgical time. Virtual reality is also being used to manage pain during painful medical procedures and in the treatment of patients with anxiety, addiction, phobias and posttraumatic stress disorders. In addition, the technology is helping to educate future physicians and nurses. In 2015, Case Western Reserve University and Cleveland Clinic broke ground on the $515 million Health Education Campus, which will house advanced technology, such as augmented and virtual reality systems, to teach medical students about human anatomy without using cadavers.