News From ACFAS

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To better reflect the content of the research studies submitted and being presented at ACFAS 2014 in Orlando, there has been a slight edit in titles of the following sessions:

• Session 5 is now Original Investigations—Foot and Ankle Reconstruction
• Session 18 is now Original Investigations—Diabetic Foot/Forefoot Reconstruction/Basic Research
• Session 25 is now Original Investigations—Foot and Ankle Trauma/Other

The changes come from a new presentation scheduling system designed to group the presentations by classification within sessions. The new titles more accurately identify what attendees will hear.

If you previously registered for any of these sessions, you are still registered. This notice is for informational purposes only. If you have further questions, please contact the Education Department. Let ACFAS help you make and keep a New Year’s resolution to yourself to explore the latest in new research with Scientific Literature Reviews (SLRs). These research reviews are brought to you monthly by various Residency Programs and give you a quick insight into some of the latest foot and ankle surgery research from journals that may not be at the forefront of your reading list. SLRs can be found at acfas.org/slr each month and are archived for the year.

The latest SLRs for January 2014 include:

• The Prognosis of Patients on Hemodialysis with Foot Lesions
• Subtalar Distraction Arthrodesis Using Fresh-Frozen Allogeneic Femoral Head Augmented With Local Autograft
• A Plantar Closing Wedge Osteotomy of the Medial Cuneiform for Residual Forefoot Supination in Flatfoot Reconstruction
• Internal Splinting: A New Technique for Achilles Tendon Repair
• Treatment of Osteochondral Lesions of the Talus with Particulated Juvenile Cartilage
• Comparison of Extramedullary Versus Intramedullary Referencing for Tibial Component Alignment in Total Ankle Arthroplasty
• Surgical Results of Zones I and II Fifth Metatarsal Base Fractures Using Hook Plates
• Peripheral Neuropathy as Initial Manifestation of Primary Systemic Vaculitides
• Outcomes of IED Foot and Ankle Blast Injuries

Listen to the most recent editions to the educational podcasts from ACFAS and hear the latest from an expert panel of your peers on the hottest topics.

The newest releases include Charcot Reconstruction: Internal or External Fixation or Both?, where you’ll hear some of the best ways to intervene in the treatment of Charcot and how the experts treat some of the most difficult cases; and Peroneal Tendons – The Forgotten Tendon, which explores diagnostic pearls, surgical management and rehabilitation, and even an international view on treating conditions of the Peroneal tendon.

To hear these and other thought-provoking podcasts, visit acfas.org/podcasts.

Foot and Ankle Surgery

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End-stage ankle osteoarthritis patients who underwent three-component, mobile-bearing total ankle arthroplasty had a more normalized gait over a year after the procedure compared to patients who were treated with arthrodesis, a new study has found. Researchers examined 17 patients who underwent total ankle arthroplasty, 17 who were treated with arthrodesis, and 10 matched control subjects who were examined for comparison purposes. Gait analyses were performed on 17 patients who underwent total ankle arthroplasty (TAA), 17 who were treated with arthrodesis, and 10 matched controls. Patient-reported Ankle Osteoarthritis Scale and Short Form-36 (SF-36) were also administered. The study found that while gait patterns in the both TAA and arthrodesis groups were not completely normal, the gait patterns of patients in the TAA group were closer to the control largely because of the greater dorsal motion in the sagittal plane. Patients who underwent TAA displayed greater postoperative total sagittal plane motion, dorsiflexion, and range of tibial tilt compared to patients in the arthrodesis group. However, improvements in patient-reported Ankle Osteoarthritis Scale and SF-36 scores were similar in both groups. The findings could be used for future modifications of ankle prostheses and could help clinicians better inform patients about the predicted functional outcomes of the two procedures prior to treatment.


Lateral ligament reconstruction with allograft is an effective form of treatment for patients with severe chronic lateral ankle stability, a new study has concluded. Surgeons retrospectively examined 10 severe chronic lateral ankle instability patients who were treated with allograft non-anatomic ligamentoplasty at an average age of 29 years. Both before surgery and at follow-up, which was performed at an average of 16.3 months after surgery, patients were evaluated using the American Orthopaedic Foot and Ankle Society score, radiographic laxity testing using telos stress equipment, and the Sefton stability scale, among other metrics. Patients displayed significant improvement in all the metrics at follow-up compared to before the operation. Most of the patients involved in the study rated their outcome as being either good or excellent. Finally, improvements in joint stability were seen using telos stress radiographs.

Practice Management

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Medical practice managers should be sure to have a process in place for handling employee reviews and raises. The first step managers should take in this process is to establish a written set of their goals for staff members that are challenging but attainable, clear, and measurable. Next, goals should be established for staff members themselves. Such goals can include tangible, measurable objectives as well as intangible goals. After managers create a set of goals for staff members, they should hold a meeting with employees to allow them to raise questions and clarify any issues surrounding the manager's personal management goals and the goals for staff members. At this point, staff members should be given the opportunity to approve both sets of goals. However, new goals can be added even after the initial set of goals is approved. These new goals should be reviewed individually until they are achieved. Managers should also be sure to establish a written schedule and structure for carrying out employee reviews. Finally, managers should remember that raises should not be given to employees who fail to demonstrate improvements in their performance. Pay increases should be reserved only for those who obtain certifications, licensure, or show improvements in their skills.


There are a number of best practices doctors and other prescribers can follow in order to minimize any legal liability stemming from adverse events in patients who are prescribed drugs with black box warnings. For instance, clinicians should be sure to document that they took the time to consider whether there was an equally effective and safer alternative to the black-box drug they wanted to prescribe, and if not, whether the potential benefits of the black box drug outweighed the safety concerns. This information, as well as information about whether the patient is an appropriate candidate for the drug, should be clearly documented and placed in the patient's medical record. Clinicians should also be sure to obtain informed written consent from the patient stating that he was warned about the risks associated with the black box drug, as well as the risks and benefits of other drugs and no treatment at all. This informed consent should state that the patient discussed these issues with the clinician prior to agreeing to be treated with the black box drug. If the clinician is unable to obtain written informed consent, the patient's medical record should show that he was told of the warnings and that he agreed to be treated with the black box drug after being informed of the risks, benefits, and alternatives.

Health Policy and Reimbursement

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Physicians are likely to face a number of challenges in the new year, many of which stem from legislation and government regulations. For example, the implementation of most of the Affordable Care Act's key provisions is expected to have a negative impact on the physician reimbursement system--a system that has already drawn complaints from doctors due to declining reimbursement rates. The number of patients who are expected to have insurance coverage is expected to grow next year thanks to ACA, and as many as 80 percent of these individuals could be at high risk of non-payment. As a result, some physicians are likely to opt to move from collecting payments for services after they are provided to charging for treatments in advance, says Nate Davis, the product manager at the healthcare information technology and management solutions company ZirMed. Another challenge that physicians are likely to face in 2014 is the Oct. 1, 2014 deadline for switching to the International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) coding system for billing. Practices that are not using ICD-10-CM will no longer be reimbursed by third-party payers. Finally, doctors will have to attest to Meaningful Use Two (MU2) next year, which could be difficult given the challenges involved in exchanging patient health information with other healthcare providers.


The Department of Health and Human Services (HHS) says it has added 123 additional accountable care organizations (ACOs) to the Medicare Shared Savings Program, bringing the total number of Medicare ACOs to over 360. The new ACOs, most of which are physician-led and serve less than 10,000 beneficiaries each, collectively provide care to roughly 1.5 million Medicare enrollees. Some of the ACOs that have been added to the Medicare Shared Savings Program--which provides financial incentives to ACOs that deliver less expensive care while simultaneously meeting targets on 33 quality measures--were among the ACOs that dropped out of the Centers for Medicare and Medicaid Services (CMS) Innovation Center's Pioneer ACO program last summer. HHS Secretary Kathleen Sebelius lauded the addition of the ACOs to the Shared Savings Program, saying that it underscores how the Affordable Care Act is rewarding healthcare providers that work together to help Medicare beneficiaries receive the best care possible. However, little information is available about the performance of the ACOs that were early adopters of the Shared Savings Program last year.


Medicare has published the results of an analysis that examined which of the nation's hospitals were the best at performing joint replacements. The analysis, which was performed as part of the federal government's effort to improve the quality of care provided at hospitals, examined the rate at which patients were readmitted to hospitals within 30 days after being discharged following a joint replacement. The analysis also examined how often patients suffered one of eight complications, including blood clots, mechanical complications, or death, after the joint was replaced. Patients at 97 hospitals had the best recoveries from surgery, the analysis found. But patients at 95 other hospitals experienced problems following surgery. Nine of those 95 hospitals had high readmission and complication rates. The hospitals that were cited as having high readmission and complication rates say that they have taken steps to bring both of those metrics down since the July 2009 to June 2012 period that was covered by the analysis. One step some hospitals are taking to reduce readmission rates is to educate joint replacement patients about how to care for themselves and what warning signs they should watch for after their surgery.


The Centers for Medicare and Medicaid Services (CMS) has issued a final rule that describes how certain eligible professionals can reassign electronic health record (EHR) incentive payments to Method II critical access hospitals (CAH). The rule, which applies to both Medicare and Medicaid as well as EPs who demonstrate meaningful use under the EHR Incentive Programs, outlines a two-step process for handling the reassigning of EHR incentive payments for payment year 2013. The first step calls for CMS to identify hospital-based EPs by using data from Method II CAH claims for fiscal year (FY) 2013. EPs that are found to be non-hospital-based will be eligible to demonstrate meaningful use for the 2013 EHR reporting period and could qualify for an EHR incentive payment for payment year 2013. In the second step, CMS will check the hospital-based determinations that were made for EPs under the existing regulation using FY-'12 claims data. EPs that are subsequently found to be non-hospital-based will be given that designation for payment year 2013. CMS also said that it will use the most recent 12-month cost reporting period available at the time of settlement to determine the amount of the final EHR incentive payment to the Method II CAH in cases where there is no 12-month cost reporting period that begins on or after the beginning of a payment year. The new rule will affect claims submitted after Oct. 1, 2012.

Medicine, Drugs and Devices

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An analysis of pooled data from five Phase III trials has found that the tumor necrosis factor (TNF) inhibitor Simponi is about as safe as older anti-TNF agents in treating rheumatic diseases through three years of follow-up. The analysis focused on the reports of adverse events that occurred in the trials, in which 2,303 patients with rheumatoid arthritis, psoriatic arthritis, or ankylosing spondylitis were given either a 50 mg or a 100 mg dose of Simponi or a placebo. Doses of Simponi, which was administered subcutaneously once a month with or without methotrexate, could be adjusted if the investigators performing the study felt the need to do so. The analysis found that the incidences of serious infection per 100 patient-years were 5.31 in patients given a placebo, 3.03 in patients given the 50 mg dose of Simponi, and 5.09 for patients treated with the 100 mg dose. The analysis also found that at the three-year follow-up point, at least one adverse event was reported by 73.6 percent of patients who took a placebo for an average of 28.1 weeks, 85.6 percent of patients who took 50 mg of Simponi for an average of 93.4 weeks, and 86.7 percent of patients who were given 100 mg of Simponi for 115.1 weeks. Infections, which were the most common type of adverse event, were reported by 34.6 percent, 60.4 percent, and 64.3 percent of patients in the placebo, 50 mg, and 100 mg groups.


A new randomized, double-blind, placebo-controlled Phase IIa trial has found that a single dose of a photodynamic topical antimicrobial gel containing RLP068 is safe and effective in treating infected foot ulcers in patients with Type 1 or Type 2 diabetes. Researchers used 0.1 percent, 0.3 percent, and 0.5 percent concentrations of RLP068 in conjunction with a systemic treatment of amoxicillin and clavulanic acid and measured patients' total and pathogen microbial load both before and one hour after the gel was applied and photoactivated. Microbial load was also measured on days three, eight, and 15. Blood samples were drawn at one, two, and 48 hours after the gel was administered in order to assess systemic drug absorption. Researchers observed a dose-dependent reduction in total microbial load immediately after all three concentrations of RLP068 were photoactivated, though the effect steadily faded during follow-up. An analysis of adverse events uncovered no safety issues associated with the use of the gel. Researchers concluded that additional studies need to be performed to verify the effectiveness of the antimicrobial gel when used as an add-on to systemic antibiotic treatment.


A new study examined how well Fluorine-18-Fluorodeoxyglucose ((18)F-FDG) positron emission tomography (PET) and PET/computed tomography (PET/CT) performed in the diagnosis of osteomyelitis related to diabetic foot. Researchers performed a quantitative analysis on four studies in which (18)F-FDG-PET and PET/CT was used on patients with diabetic foot, and calculated pooled sensitivity, specificity, positive and negative likelihood ratio (LR+ and LR-) and diagnostic odds ratio (DOR) as well as the area under the summary Receiver Operating Characteristic (ROC) curve of the two diagnostic procedures. On a per patient-based analysis, sensitivity was 75 percent, specificity was 91 percent, LR+ was 5.56, LR- was 0.37, and DOR was 16.96. The area under the summary ROC curve, meanwhile, was 0.874. Researchers concluded that the high level of specificity was an indication that (18)F-FDG-PET and PET/CT are potentially useful in diagnosing osteomyelitis related to diabetic foot, so long as the tools are used in conjunction with magnetic resonance imaging (MRI) or other imaging methods. Researchers added that despite their findings, there is a limited amount of literature available that focuses on the use of (18)F-FDG-PET and PET/CT in the diagnosis of osteomyelitis related to diabetic foot.