News From ACFAS

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As your source for lifelong foot and ankle learning, ACFAS has added orthobiologics to its e-Book series with The Art and Science of Orthobiologics for the Foot and Ankle. This second e-Book release guides you through the newest bone graft materials and techniques to help you achieve optimum patient outcomes.

Twelve chapters written by 25 renowned experts in the field and nearly 150 full-color images give you an unprecedented look at orthobiologics’ role in bone healing and growth. Get the most from your reading with built-in notetaking and bookmarking tools and also earn CME by completing a short self-assessment after each chapter.

Visit acfas.org to purchase the e-Book now, and watch This Week @ ACFAS for updates on other e-Books in production. Give back to the profession and share your expertise by applying to join the ACFAS faculty. The College’s education committees are looking for new faculty members and instructors to help lead and expand our surgical skills courses, regional programs, e-Learning offerings and Annual Scientific Conference sessions.

If you’re an active Fellow member of the College, have attended our educational programs within the past three years and have been in practice for more than four years, complete a Faculty Application and fax it to the ACFAS Education Department at (800) 382-8270. You may also email your application to Mary Meyers, ACFAS director of Education Curriculum and Alliances. Congratulations to the 2017 ACFAS Division Scholars! Each Student Scholar received a scholarship from his or her respective ACFAS Regional Division to attend this year's Annual Scientific Conference in Las Vegas. Individual scholar photos can be found on each Division’s webpage.

Division 1: Pacific
CSPM: Lance Hopkin, Class of 2019
WesternU: Pedro Aldape Esquivel, Class of 2019

Division 4: Desert Valley
AZPod: Garrett Nguyen, Class of 2019

Division 5: Florida
Barry: Elizabeth Ansert, Class of 2019

Division 6: Midwest
DMU: Zach Croy, Class of 2019
Scholl: Alexander Lawson, Class of 2019

Division 9: Greater New York
NYCPM: Brent Blanck-Singer, Class of 2019

Division 12: Tri-State
Temple: Anthony Samaan, Class of 2019

Division 13: Ohio Valley
Kent State: Britain Wetzel, Class of 2019

Foot and Ankle Surgery

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A study was conducted to investigate whether blood flow in the Achilles tendon has an association with patient-reported and functional outcomes after acute Achilles tendon rupture (ATR). The researchers employed in vivo laser Doppler flowmetry to evaluate bilateral microvascular blood flow in the Achilles tendons during postocclusive reactive hyperemia of nine patients with acute total ATR at two weeks after surgery. Three months later, patient-reported outcome was assessed using Achilles tendon Total Rupture Score (ATRS). At 12 months, a uniform outcome score, Achilles Combined Outcome Score (ACOS), was acquired through a combination of validated, independent, patient-reported and functional outcome measures. The researchers correlated an improved ACOS at one year with higher maximum blood flow in the injured limb. In addition, enhanced patient-reported outcome, ATRS, at three months was associated with a higher ratio of maximum to resting blood flow in the uninjured limb.


The goal of this study was to evaluate the psychometric properties of the Finnish version of the Lower-Extremity Functional Scale (LEFS) among foot and ankle patients. The LEFS was translated and cross-culturally adapted to Finnish. Researchers assessed the test–retest reliability, internal consistency, floor-ceiling effect, construct validity and criterion validity in 166 patients who underwent surgery due to musculoskeletal pathology of the foot and ankle. The LEFS correlated strongly with the 15D Mobility dimension and overall HRQoL pain during foot and ankle activity and stiffness. The Finnish LEFS showed high internal consistency, and a slight ceiling effect occurred as 17 percent achieved the maximum score. LEFS correlated moderately with foot and ankle pain at rest and with physical activity. This study indicates that the Finnish version of the LEFS serves both clinical and scientific purposes in assessing lower-limb function. Investigation of the psychometric properties of the Finnish version of the LEFS showed validity and reliability comparable to those of the original English version. The Finnish LEFS is easy to complete and suitable for clinical, rehabilitation and research purposes.


The most common type of ankle fracture is isolated type B ankle fractures with no injury to the medial side. Researchers sought to determine if surgery is superior to nonsurgical management for the treatment of these fractures. Participants between 18 and 65 years old with a type B ankle fracture and minimal talar shift were recruited from 22 hospitals in Australia and New Zealand. Participants were randomly allocated to undergo surgical fixation followed by mobilization in a walking boot for six weeks. Those treated nonsurgically were managed in a walking boot for six weeks. Outcome assessors were blinded for the primary outcomes. Patient-reported ankle function was assessed using the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire (FAOQ) and the physical component score (PCS) of the SF-12v2 General Health Survey at 12 months after injury. Primary analysis was intention to treat; the randomized and observational cohorts were analyzed separately. From August 2010 to October 2013, 160 people were randomized (80 surgical and 80 nonsurgical); 139 (71 surgical and 68 nonsurgical) were analyzed as intention to treat. The randomized cohort demonstrated that surgery was not superior to nonsurgery for the FAOQ or the PCS. In addition, 23 (32 percent) and 10 (14 percent) participants had an adverse event in the surgical and nonsurgical groups, respectively. Similar results were found in the observational cohort. The researchers concluded that surgery is not superior to nonsurgical management for 44-B1 ankle fractures in the short term and is associated with increased adverse events.

Practice Management

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In the first year of the Medicare Quality Payment Program, under the Medicare Access and CHIP Reauthorization Act's Merit-Based Incentive Payment System (MIPS), physicians can submit as little as one quality measure improvement activity for any time period in 2017 and avoid a financial penalty. However, not submitting any data will result in a four percent payment penalty two years from now. Speaking at the American College of Physicians conference in San Diego, Tom Lee, PhD, MBA, chief executive officer and founder of software solution provider SA Ignite, encouraged physicians to maximize their efforts. Annual scores will be published on the Physician Compare website, and the data will be shared with other third-party ratings sites, including HealthGrades, Yelp and Google. As a result, a low score could be seen by patients and others online. Moreover, the score follows physicians who switch organizations, essentially becoming part of their permanent file, and the reputational damage could affect mergers and acquisitions, contracting and other evaluations of the physician. Lee also said electronic health records can be a strong asset in collecting and submitting data and added that it would be wise for physicians to set a score goal early on for where they want to be in the future and understand what it will take to get there.


Remote access to a practice's electronic systems is a must, partly due to the advent of cloud-based practice management and electronic health record systems. However, managers are still responsible for the practice's devices and confidential data sent over the public Internet. They must therefore cover four important elements: device security, network connection security, data security and safe computing practices. For the first element, managers need to ensure they apply all software updates, use good passwords, enable encryption of the device itself and its storage and make sure physical security is solid. To secure Internet connections, managers should consider a virtual private network service, which encrypts all data coming into and out of the device. This is particularly vital if public Wi-Fi is used, while the best option is to purchase and use a cellular Wi-Fi hotspot or tethering from cell phones. The optimal choice for data security is a secure cloud service, with downloading or copying data to the device's local storage discouraged. Access to secure email should only be done through a secure Web browser connection. Finally, recommended safe computing practices include not using easily guessed passwords or the same password on multiple websites or systems. In addition, staff must avoid clicking links in phishing emails and sharing passwords with others, while a laptop or phone should never be left visible in a locked car.


Healthcare professionals are embracing mobile technology, according to a new HIMSS Analytics study. HIMSS Analytics surveyed 129 C-suite executives, IT professionals, clinicians and department heads and found 79.8 percent use tablets and 42.6 percent use smartphones to access the information needed to provide and coordinate care. The study also reveals 76.5 percent use smartphone applications to access clinical information, 70.6 percent use smartphones to access electronic health records and 66.2 percent use smartphones to access nonclinical information, such as educational resources. "However, the use of mobile technology has not easily translated to clinician needs around providing better patient care," says Brendan FitzGerald, director of research at HIMSS Analytics. Continued innovation in the use of mobile technology is needed to improve care quality and workflow efficiencies, adds FitzGerald. HIMSS Analytics also reports 37.2 percent of healthcare professionals use laptops and 94.6 percent still use desktop computers.

Health Policy and Reimbursement

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Physicians and drugmakers are both heavily critical and skeptical of the Medicare Payment Advisory Commission's (MedPac) latest proposal to change the way drugs are paid for under Medicare Part B. The commission unanimously voted to urge Congress to enact new drug reimbursement laws that would lower Medicare spending by up to $750 million in the first year of implementation and $5 billion over five years. MedPac's suggestions include cuts to wholesale prices and market-based negotiation to help stanch climbing drug costs for the Part B program. At present, Medicare pays six percent above wholesale cost for new drugs given by infusion or injection in physicians' offices and hospital outpatient departments. That means providers earn more when they choose more costly medications. After a drug has been on the market for several months, Medicare pays six percent on top of the average sales price of the medication, which critics argue incentivizes the practice of physicians recommending costlier drugs. Medpac's proposal would cut payments over wholesale cost by three percent next year. The commission also suggested requiring drugmakers to submit average sales price data to the U.S. Centers for Medicare and Medicaid Services or face fines for noncompliance. MedPac also proposed drugmakers pay Medicare a rebate when the average sales price tops a congressionally established inflation benchmark. The Pharmaceutical Research and Manufacturers of America warn this policy could choke innovation.


There is a mismatch between data from the nonprofit Leapfrog Group and Medicare data that implies a dearth of reliability in self-reported hospital quality information, according to a University of Michigan study published in Health. The researchers indicate Leapfrog's Safe Practice Score (SPS) generates different results than those used by Medicare's Hospital Compare to track common complications and readmissions. The study suggests the Leapfrog findings "skew toward positive self-report[ing]," with implications that some of the dissimilarities are rooted in "selection effects." The Michigan team says hospitals may be more likely to share information if they generally earn high scores. "Alternatively, given that hospitals have a clear incentive to score themselves highly, participating hospitals may inflate their SPS reports, resulting in the skewed distributions and undermining the measures' predictive value," they note. In response, Leapfrog counters that although gaming any ratings system is possible, "we find that hospitals attempting this with the Leapfrog Hospital Safety Grade are generally frustrated by the result." The group says its safety grade is based on 30 measures, "meaning that there are thousands of potential statistical outcomes that cannot be predicted with certainty." In addition, Leapfrog says it "goes to extreme lengths" to verify survey data via on-site verification at randomly chosen facilities and independent reviews of each survey response.


The federal government has raised its final payment rate for health insurers who offer Medicare Advantage plans for seniors and the disabled, settling on a 0.45 percent increase on average for next year. Medicare Advantage is an alternative to the standard fee-for-service Medicare in which private insurance companies manage health benefits. Currently, it is the fastest growing form of government healthcare, with 18 million people enrolled last year. This latest change in the final rate reflects the government's assessment that effective spending growth will be lower than initially projected. Among the insurers that provide these plans are Aetna Inc., Humana and UnitedHealth Group Inc.

Medicine, Drugs and Devices

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To mitigate the penalties they often suffer for hospital-acquired infected bedsores, medical facilities are starting to invest in smart beds that automatically turn patients every few hours. The units can move in all directions, tilt at different angles and extend for very tall patients. They can also weigh patients and perform vibration and percussion massages. In addition, the beds can sense the patient's position, notify clinicians regarding any issues and send the data to the hospital's electronic medical record. Affordability is a major challenge for hospitals, as the price of smart beds can range from $10,000 to $40,000. One hospital bed provider, Hill-Rom, is testing different technologies and exploring development of a bed that can run the patient's data through sophisticated algorithms to anticipate if the patient will move or get out of bed. The U.S. hospital bed market amounted to $1.2 billion last year and is expected to grow at an annualized rate of 2.8 percent and total $1.4 billion by 2021, according to an IBISWorld study.


Permitting patients to enter previsit agendas into the electronic health records system prior to seeing the physician makes appointments more efficient and improves communication, according to a new OpenNotes study published in the Annals of Family Medicine. The researchers determined that allowing 101 patients to type in previsit agendas before a physician's appointment improved self-reported communication and efficiency. The surveys found patients and physicians agreed or strongly agreed that the process made physicians more prepared, improved physician understanding of patient concerns, boosted the efficiency of visits, helped prioritize the visit and enhanced patient-physician communication. In addition, both physicians and patients said they want to use patient agendas in the future. Agendas were found to be brief overall, with 83 percent of patients typing for less than 10 minutes and 80 percent typing less than 60 words.


Residential treatment for opioid addiction cannot accommodate all victims, the population of which is exploding when those abusing heroin and prescription painkillers are accounted for. The federal government has sought to partly address this by granting California, Maryland, Massachusetts and New York a waiver of a little-known Medicaid rule barring federal funding for treatment provided in places with more than 16 slots. Arizona, Indiana, Illinois, Kentucky, Michigan, Utah and Virginia are requesting similar waivers. All states are being encouraged by the federal government to seek waivers of the Medicaid rule, provided the care is offered as part of a comprehensive set of addiction services for low-income people.