News From ACFAS

---

As the curtain rises on ACFAS 2018 here in Nashville and attendees begin to fill the Gaylord Opryland Hotel and Convention Center, we can tell that these next few days will be a performance like no other. With preconference workshops underway today and everyone excited for tomorrow’s opening session starring Captain Mark Kelly of NASA, ACFAS 2018 promises to be a chart topper!

This show is by no means one night only—we’ll be in town until Sunday, March 25 with plenty of sessions, workshops and special events scheduled between now and then!

Plans for next year’s Annual Scientific Conference in New Orleans are already in the works. Mark your calendars now for February 14–17, 2019. Use #ACFAS2018 in your social media posts to join the conversation about our Annual Scientific Conference here in Nashville. Also, whether you're here at the conference or at home, you can follow #ACFAS2018 on Twitter, Facebook and LinkedIn to stay ahead of everything happening each day. Plus, be sure to check out the latest posts, photos and videos from your colleagues through the ACFAS 2018 mobile app's social media feature.
Do your practice marketing efforts need a refresh? Download the latest issue of FootNotes from the ACFAS Marketing Toolbox and use it to promote your practice and educate your patients this spring.

Articles in this edition include:

• Prepare for Spring Walkathons to Avoid Foot & Ankle Injuries
• Is Foot Pain Ruining Your Golf Swing?
• Foot Health Facts on Children’s Foot Conditions

Customize page 2 of FootNotes with your office’s contact information then post the issue on your practice’s website, distribute printed copies to your patients or bring FootNotes to any upcoming speaking engagements or community health fairs.

Visit acfas.org/marketing often for many other free resources, including infographics, PowerPoint presentations, healthcare provider referral tools and fill-in-the-blank press releases, that make marketing your practice and educating your patients easy.

Foot and Ankle Surgery

---

The goal of this study was to demonstrate the effectiveness of an innovative, minimally invasive surgical procedure to treat comminuted intraarticular calcaneal fractures. The procedure consists of a closed reduction technique using large-diameter Steinmann pins, in addition to percutaneous calcaneoplasty using injectable calcium sulfate cement. From January 2012 to January 2014, 20 patients with comminuted calcaneus fractures were included. The surgery was performed within three days post injury, and patients were not allowed to bear weight until three months postoperatively. During this period, the patients were instructed how to perform bed exercises for joints above the surgical site. Early active range of motion exercises for the ankle and forefoot began three weeks to six weeks postoperatively. After an average follow-up of two years, none of the patients required further surgery or experienced soft-tissue complications. The clinical results were rated good to excellent on the American Orthopaedic Foot and Ankle Society ankle score in 80 percent of the cases, and most patients had pain relief and returned to their former daily activities at the same level as before the injury. A modified Essex-Lopresti procedure with percutaneous calcaneoplasty appears to be a safe and effective procedure for treating comminuted calcaneal fractures with acceptable functional results. However, long-term outcomes and additional cases using this technique are required to support this conclusion.


Reconstruction of complicated diabetic lower leg and foot defects involving multiple tissue components remains a challenge. The objective of this report is to introduce thoracodorsal artery perforator (TDAP) chimeric flaps for reconstructing diabetic lower leg and foot soft-tissue defects. Between April 2010 and August 2016, 17 patients with multiple diabetic lower leg and foot defects underwent reconstruction with TDAP chimeric flaps. Nine were women, and the mean age of the patients was 57.7 years (range 35-73 years). One patient had three separate defects, 14 patients had two separate defects and two patients had defects with dead space. The size of the defects ranged from 5 × 3 cm to 20 × 10 cm. Fifteen patients received TDAP chimeric flaps with two components (skin and muscle components), and two received three components. All flaps survived except for partial loss of one muscle component. Four patients suffered postoperative complications, including wound disruption and infection, all of which healed conservatively. The mean follow-up was 31.3 months (range 8–60 months). Fifteen patients were able to walk, one patient walked with a walker and one patient who had amputation due to Charcot joint infection walked with a prosthesis. The findings suggest that the TDAP chimeric flap may be another option for the complex wound coverage required to reconstruct diabetic lower leg and foot soft-tissue defects.


The most common reason for a revision total ankle replacement procedure is a painful, stiff ankle following initial surgery. Conflicting and limited findings are available regarding the change in sagittal foot and ankle range of motion after revision total ankle replacement surgery. Researchers sought to determine whether revision total ankle replacements would reduce compensatory midfoot range of motion. In determining this, a novel radiographic measurement system with stable osseous landmarks was used. A retrospective medical record review of patients who underwent revision total ankle replacement from January 2009 to June 2016 was performed. Thirty-three patients (33 ankles) underwent revision total ankle replacement surgery and met the inclusion criteria with a mean follow-up period of 28.39 ± 14.68 months. Investigation of preoperative and postoperative weightbearing lateral radiographic images was performed to determine the global foot and ankle, isolated ankle and isolated midfoot sagittal ranges of motion. Statistical analysis revealed a significant increase in ankle range of motion and a significant decrease in midfoot range of motion from preoperatively to postoperatively. The change in global foot and ankle range of motion was not significant. For this patient population, the increased ankle range of motion effectively resulted in less compensatory midfoot range of motion.

Practice Management

---

Michael Hodgkins, MD, CMIO at the American Medical Association (AMA), blames electronic health records (EHRs) for the problem of physician burnout, which affects about half of practicing doctors. For every hour physicians spend on direct patient care, they spend two hours on EHR data entry and other administrative tasks. Addressing a CMIO roundtable at the HIMSS18 conference in Las Vegas, Hodgkins said, "When physicians are not involved in how these tools are created, designed and implemented, there are problems." A paper published last year in Health Affairs concluded that physician burnout is a nationwide public health crisis. According to Hodgkins, replacing a physician who leaves a medical practice because of burnout can cost anywhere from $500,000 to $750,000.


A practice's website provides the first impression when a new or potential customer conducts online research. Physicians can go to their competitors' websites to see what kind of an impression they are leaving on their visitors. They should ask questions, such as:

• Are their sites clear or cluttered?
• Do they have clear navigation?
• Can they be accessed on a mobile device?

Next, practices should examine every aspect and then compare them with their own website. Ideally, the practice's website should be visually pleasing, educational and have easy-to-understand content. This includes office details, physician bio, specialty and services. The site also needs to have strong search engine optimization to ensure high rankings on online searches. Furthermore, practices need to proactively check the numerous review platforms, such as Yelp, Healthgrades and Vitals, and reply accordingly. It is a good idea to look at competitors' ratings to identify what they may be doing better and to formulate strategies around these findings. Practices can also request reviews and conduct surveys of satisfied patients when they visit or through mail and messages. Patients should also be asked about their preferred social media mode of communication and whether they have anything to share about the practice or their experience.


Just 17.5 percent of employees at Mission Health in Asheville, NC, reported being "fully engaged" two years ago based on a standard employee engagement survey, according to Ronald A. Paulus, MD, Mission's president and CEO. A year and a half later, 40 percent of employees reported being fully engaged. Mission experienced this improvement by implementing what Paulus describes as "a three-legged stool." The first and foremost leg is continuous feedback. Using an app, each team member checks in with his or her team leader at the beginning of every week. The team members also list their priorities for the week. The second leg is called "Mission Renew," which involves shadowing employees to "collect and amalgamate their hassles and joys," Paulus explains. In many cases, the hassles derive from information technology. Mission Health has created a path in its career development center created particularly for nonphysicians to retrain people who love the company, but not their individual job responsibilities. The third and final leg of the stool revolves around helping staff cultivate "individual resilience" based on a productivity program formed by a company called Life XT. The approach uses "scientific evidence for resilience by drawing on common characteristics in other cultures, such as meditation, gratitude and engagement in activities beyond the self," according to Paulus. However, he makes clear that individuals are never left to figure it out on their own.

Health Policy and Reimbursement

---

A recent study in the Journal of the American Heart Association found that 30-day mortality rates for acute myocardial infarction or heart attack patients were 12.8 percent for hospitals that spent the most on care and 13.5 percent for those that spent the least on care. The average amount spent per beneficiary in a hospital that spent the least was slightly more than $20,000 versus $24,000 for higher spending hospitals. The findings come as the U.S. Centers for Medicare and Medicaid Services (CMS) wants to reduce Medicare spending on heart attack patients, which hovers around $12 billion every year. Clinicians hope the study spurs CMS to abandon plans to hold providers accountable for how much it costs to care for heart attack patients, noting that the study shows higher spending leads to better health outcomes. Dr. Gregg Fonarow, director of the Ahmanson-UCLA Cardiomyopathy Center, says he is concerned such efforts could raise mortality rates for heart attack patients the way the Hospital Readmissions Reduction program appeared to raise death rates for heart failure patients. Dr. Ashish Jha, a professor of global health at the Harvard School of Public Health, observes, "CMS says we will pay you less if you spend too much because that shows inefficiency, but that policy is the opposite of improving quality." Some are doubtful the study could convince CMS to change its course, especially because mortality rates were only modestly different between high and low spending hospitals.


Federal law has been revised so eligible Medicare beneficiaries will still be able to use therapy services even if they exceed their allotted yearly benefits. The federal budget plan approved by Congress in February eliminates annual caps on how much Medicare pays for physical, occupational or speech therapy and simplifies the medical review process. It is applicable to people in traditional Medicare as well as those with private Medicare Advantage policies. Since January 1, Medicare beneficiaries have been eligible for therapy indefinitely, provided their doctor—or in some states, physician assistant, clinical nurse specialist or nurse practitioner—verifies their need for therapy and they continue to meet other mandates. The U.S. Centers for Medicare and Medicaid Services told healthcare providers about the amendment last month. Another key revision permits private Medicare Advantage plans in 2020 to offer special benefits to members with a chronic illness and who meet other criteria. These plans currently limit members to a network of providers and give all members identical treatment, but the budget law says benefits targeting those with chronic illnesses do not need to be primarily health-related and only require a "reasonable expectation" of improving health.


The Medicare Payment Advisory Commission (MedPAC) on March 15 issued its semiannual report to Congress recommending that lawmakers end the Merit-Based Incentive Payment System (MIPS). Instead, MedPAC proposes adopting a Voluntary Value Program (VVP) that it says would ease the administrative burden on physicians and more objectively assess the value of the care based on population health metrics. MedPAC Executive Director James Mathews said the commission concluded that MIPS has certain fundamental flaws, which make the program "inequitable among physicians." He called the VVP a more streamlined approach that leaves the bulk of data compilation to Medicare through readily available claims or beneficiary satisfaction surveys. Unlike MIPS, which allows clinicians to choose from 300 different quality measures, the VVS has six measures that clinicians can choose from. Physicians would not be measured on an individual basis but would be measured as a group on a much smaller set of population-based outcomes measures, he said. Those outcomes could include hospital admissions, mortality rates in the population they serve and Medicare spending per beneficiary for the patients they meet. Mathews says the program would be voluntary, and physicians would receive incentives for participating in it.

Medicine, Drugs and Devices

---

A study published in the Journal of Endocrinology found that an active metabolite in the rheumatoid arthritis treatment leflunomide may inhibit a protein that affects insulin-receptor signaling in mice. This suggests that the anti-inflammatory drug could be a potentially effective treatment for type 2 diabetes. Individuals with rheumatoid arthritis have a higher risk for developing type 2 diabetes and obesity than those without rheumatoid arthritis, noted Xiulong Xo, PhD, professor at the Institute of Comparative Medicine at Yangzhou University, China, and colleagues. They found that the inhibition of S6K1 activity by A77 1726, an active metabolite in leflunomide, led to the inhibition of insulin-receptor signaling in mouse and rat myotubes, as well as in mouse adipocytes under both normal and insulin-resistance conditions. The researchers also investigated the anti-hyperglycemic effect of leflunomide in obese and high-fat diet-induced diabetes mouse models and with mice fed a normal chow diet. They found that leflunomide treatment normalized blood glucose levels and overcame insulin resistance in glucose and insulin tolerance tests in the high-fat-diet mice, but treatment had no effect on mice fed a normal chow diet. "Our results suggest that leflunomide sensitizes the [insulin resistance] by inhibiting S6K1 activity in vitro, and that leflunomide could be potentially useful for treating patients with both [rheumatoid arthritis] and diabetes," the researchers wrote. They intend to conduct clinical trials with leflunomide in humans.


New research indicates that a multimodal strategy for pain relief, rather than an opioid-only approach, benefits patients after total joint arthroplasty. Tapping into 10 years' worth of information from a nationwide database, investigators studied the types of pain relievers used in more than a million knee replacements and more than half a million hip replacements. Multimodal plans—including opioids plus one or more other methods, such as peripheral nerve block, acetaminophen or gabapentin/pregabalin—were employed more than 85 percent of the time. Patients who received more than two additional types of pain relief besides opioid analgesics not only used significantly fewer opioids, they also experienced fewer respiratory and gastrointestinal complications and were discharged from the hospital sooner. "This study does not answer the question of what combinations of analgesic approaches are best. We would need to conduct a much more complicated analysis because there are so many potential combinations of drugs to consider," said Stavros Memtsoudis, MD, director of critical care services in the anesthesiology department at New York's Hospital for Special Surgery. "Future studies are needed to identify optimal multimodal regimens and patient subgroups most likely to benefit from each combination." The study appears in Anesthesiology.


Researchers at the New York Genome Center and New York University have created a 3D-printed, portable and low-cost microfluidic controller that analyzes tissue cells and can recognize fibroblast subtypes in rheumatoid arthritis patients. The researchers used the device to analyze 20,387 joint synovial tissue cells from five rheumatoid arthritis patients at the Hospital for Special Surgery and then process the samples onsite immediately following surgery. "This dataset gave us the opportunity to identify individual subpopulations of cells that could drive the progression of rheumatoid arthritis, even if they have not been previously characterized," said senior author Rahul Satija. Analyzing the complete dataset and looking for groups of similar cells allowed the researchers to identify 13 groups that represented infiltrating immune and inflamed stromal populations. Using flow cytometry, the researchers could confirm the presence of multiple groups of fibroblasts and discovered that they had distinct localization patterns with joint tissue. "Roughly an hour after surgical excision, individual cells from patient tissues were labeled for single-cell sequencing. From this work, we have classified unrecognized fibroblast subtypes that may prove to be important drug targets for our rheumatoid arthritis patients," said lead author Laura Donlin. The researchers hope that the new dataset created by the device can create a comprehensive "cell atlas" for synovial tissue for rheumatoid arthritis patients. The research was published in the journal Nature Communications.