April 19, 2017 | | JFAS | Contact Us

News From ACFAS

Don’t Miss a Beat in Nashville
Save the date for ACFAS 2018, March 22–25, 2018 at the Gaylord Opryland Hotel in Nashville—a.k.a. Music City, USA—and join us for nonstop clinical sessions and workshops that will take your skills from “studio to stage,” plus hundreds of exhibits and scientific posters to put you front and center of the latest advancements in foot and ankle surgery.

Nashville is the heart of the country music scene. Catch a show on the Opryland stage then top it off with a delicious Southern meal or head to a honky tonk bar to see which country music stars will make a surprise appearance. Come to Nashville early to take in the sights and to also participate in our special preconference workshops on Wednesday, March 21 for a sneak preview of ACFAS 2018.

Watch This Week @ ACFAS and ACFAS Update for details on ACFAS 2018 and be sure to mark your calendars now!
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Two New PowerPoints Available in Marketing Toolbox
Educate your community and patients with two new free PowerPoint presentations available for download in the ACFAS Marketing Toolbox:
  • Ankle Replacement: Today’s Solution for Debilitating Ankle Arthritis
  • Common Foot & Ankle Injuries Among Dancers
Each presentation includes a customizable slide for your practice's contact information as well as an accompanying script. Use these PowerPoints when meeting with your patients to start a conversation about foot and ankle health or when speaking at local health fairs this summer.

Bookmark and visit often for many other free resources to help promote your practice, including the FootNotes patient newsletter, infographics, fill-in-the-blank press release templates and tools for increasing referrals to your practice.
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Register Now for 2017 Coding & Billing Seminars
The expert care you give your patients deserves proper reimbursement. Learn how to achieve this in Coding and Billing for the Foot and Ankle Surgeon, July 21–22 in Philadelphia and October 13–14 in Phoenix. Through case-based and interactive discussion with faculty, you'll gain insight into:
  • CPT coding and documentation options for deformity reconstruction, arthrodesis, arthroscopy, trauma and diabetic foot surgery
  • CPT coding for minor office procedures
  • Evaluation and management surgical codes
  • Modifiers to avoid appeals
  • New government reimbursement systems and methods
You’ll also get behind the wheel and code real-time patient scenarios from start to finish for an inside look at the coding and billing process. Customized handouts, checklists and forms are yours to take with you after the seminar so you can try out your new skills back at the office. Register before May 1 to take advantage of special early bird pricing.
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Use DIY Toolkit to Increase Referrals to Your Practice
Download ACFAS’ referral marketing tools to let your local healthcare providers know who you are and why they should refer their foot and ankle patients to your practice. Available in the ACFAS Marketing Toolbox, these materials outline foot and ankle surgeons’ qualifications and can help you build relationships with these important treatment team partners in your area.

The complete toolkit includes:
  • fact sheets,
  • referral guides,
  • PowerPoint presentation with script,
  • video, press release templates and social media marketing tips.
Head to to access the tools and start raising awareness of the important work you do.
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See Highlights from ACFAS 75
Read the latest issue of ACFAS Update for a recap of the College's record-breaking 75th Anniversary Scientific Conference and to see photos from this historic event. Access ACFAS Update at and watch your inboxes for the print and e-zine versions coming soon.
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Foot and Ankle Surgery

A Predictive Model of Anxiety and Depression Symptoms After a Lower-Limb Amputation
A new study examines the immediate emotional reactions of patients with Diabetic Foot Ulcer (DFU) to lower-limb amputation (LLA) as a personal factor based on the ICF Model. Researchers conducted a longitudinal study with 179 patients with Diabetes Mellitus Type 2 and DFU indicated for amputation. They focused on the characterization of anxiety and depression levels, before and after surgery, differences in levels of depression and anxiety before and after surgery and the predictors of anxiety and depression one month after surgery, in a sample of patients with DFU. The results showed a significant effect of anxiety and depression symptoms at presurgery in the prediction of anxiety and depression symptoms one month after LLA. Patients showed higher levels of anxiety than depression symptoms at presurgery, although anxiety significantly decreased one month after surgery. Both anxiety and depression symptoms contributed to depression after LLA, although anxiety at presurgery was the only predictor of anxiety at postsurgery. Researchers conclude that tailored multidisciplinary interventions need to be developed, providing support before and after an amputation surgery, in order to reduce anxiety and depression symptoms and to promote psychological adjustment to limb loss.

From the article of the same title
Disability and Health Journal (03/27/2017) Pedra, Susana; Carvalho, Rui; Pereira, M. Graca
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Clubfoot Infants Initially Thought to Be Idiopathic but Later Found Not to Be. How Do They Do with Nonoperative Treatment?
New research seeks to determine the occurrence of infants thought to be normal with idiopathic clubfeet when nonoperative treatment begins but who are later found to have other complicating diagnoses. Researchers studied 789 patients with 1,174 clubfeet. Treatment consisted of either the Ponseti method or the French physical therapy method. In total, 70 patients (8.9 percent) were eventually found to have another disorder, including neurological, syndromic, chromosomal or spinal abnormalities. Despite this, these patients' clubfeet can be expected to respond favorably to nonoperative treatment. However, they will require more surgical intervention early (by age two years) and later (age five years and above) when compared with normal infants with idiopathic clubfeet. The researchers compared the remaining 719 idiopathic patients with 1,062 clubfeet (group one) with these 70 nonidiopathic patients with 112 clubfeet (group two). They found, for example, at age two years, in group one, 81 percent of the feet were rated good, 11 percent fair and eight percent poor, whereas in group two, 70 percent of the feet were rated good, 11 percent fair and 19 percent poor.

From the article of the same title
Journal of Pediatric Orthopaedics (04/01/17) Richards, B Stephens; Faulks, Shawne
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Functional Impairment of Patients Undergoing Surgical Correction for Charcot Foot Arthropathy
Investigations using the Medical Outcomes Study Short Form 36 Healthy Survey (SF-36) and the American Orthopaedic Foot & Ankle Society Diabetic Foot Questionnaire (AOFAS-DFQ) have demonstrated a poor quality of life in patients with Charcot foot arthropathy. Twenty-five consecutive patients undergoing operative correction for diabetes-related Charcot foot arthropathy of the midfoot completed the Short Musculoskeletal Function Assessment (SMFA) questionnaire prior to undergoing surgery. All 25 patients exhibited significant impairment in all six domains of the SMFA as compared to the normative data. There was a high correlation between each of the six domains of the SMFA, even after correcting for BMI. Charcot foot severely impaired the quality of life in patients beyond the impact of morbid obesity. This impairment equally impacted all of the functional and emotional domains measured with the SMFA as compared with population norms. This investigation provides a benchmark for measuring the impact of operative correction of the deformity. The SMFA appears to be a valid tool for measuring impairment in this complex patient population.

From the article of the same title
Foot & Ankle International (04/11/2017) Schiff, Adam; Pinzur, Michael S.; Kroin, Ellen; et al.
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Practice Management

How to Protect Your Practice When a Data Breach Hits a Partner
Healthcare data breaches involving protected health information (PHI) are growing in frequency, with nearly 90 percent of healthcare organizations experiencing a data breach in the last two years, according to a May 2016 Ponemon Institute study. Although practices track their own internal security methods to avoid compromising patient data, they also are dealing with threat of a cyberattack on one of their business partners. Cybersecurity and data privacy experts detail strategies independent practices can apply to determine how patient notification and internal security measures should be managed in the event of a business associate (BA)-based breach. Mandiant's Charles Carmakal says the initial priority is to rapidly compile as much information as possible upon notification of a BA compromise. Once the exposed data is characterized, the next step is to ascertain as many technical details about the breach as possible. Consultant Thomas Grove says when a BA alerts a practice to a potential breach, the practice should quickly determine who will lead the charge on notifying affected patients. The practice should also glean any BA contracts covering the vendor or vendors involved in the exposure. Because most independent practices cannot commit in-house employees to conduct due diligence, outside parties can be hired to do so. To respond effectively to any BA-based intrusion, practices should consider identifying all providers that may have access to patient PHI.

From the article of the same title
Medical Economics (04/10/17) Knudson, Julie
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Inspecting the Role of the Physician in ACOs
A study published in Health Affairs suggests physicians in accountable care organizations (ACOs) contribute significantly to their success. The researchers studied the Boston-based Partners HealthCare System, which supported a Medicare Pioneer ACO covering more than 82,000 beneficiaries during its initial three-year contract. They examined beneficiary distribution across physicians and changes in physicians by year. The results indicated on average that ACO beneficiaries comprised less than five percent of a physician's patients, which consequently meant the financial risk imposed by the ACO contract was unlikely to have a significant effect on physician behavior. In addition, the sickest and most expensive beneficiaries were focused among a minority of physicians, while most physicians saw ACO beneficiaries with modest costs. The team also found substantial turnover among physicians participating in the ACO. Only 52 percent of the 748 primary-care physicians were affiliated with the ACO for the entirety of the contract, while the mean number of ACO beneficiaries per physician was less than five percent of the 1,700 total patients a physician saw on average. The researchers suggest spending could be more effectively reduced through adoption of a system-level approach, instead of expecting physicians to change practice patterns for a tiny minority of their patients. As an alternative option, ACOs could try to be more efficient in driving change by concentrating more beneficiaries among fewer physicians.

From the article of the same title
Modern Healthcare (04/14/17) Whitman, Elizabeth
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The United Airlines Debacle: Four Lessons for Doctors
The recent United Airlines fiasco in which a physician was forcibly ejected from a flight due to overbooking, and his ejection caught on cell phone, carries object lessons for physician practices. The first lesson is to be aware of the potential for any bad behavior by physicians toward patients or staff to easily be captured on camera. If that happens, practices will have considerable trouble making an effective argument for their behavior, no matter how justified it may have been. The fact that many air travelers detest the practice of overbooking also has parallels to physician practices, as overbooking is a shared problem. Consequently, a damaging documented incident that spreads virally can quickly turn into a public relations headache. A final lesson for practices to be aware of is the benefit of replacing overbooking with a policy to charge patients who miss appointments and using the extra time to catch up with their backlog.

From the article of the same title
Physicians Practice (04/11/17) Perna, Gabriel
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Health Policy and Reimbursement

AMIA Details Value-Based Care Health IT Infrastructure Needs
The American Medical Informatics Association (AMIA) has made 17 policy recommendations for promoting the development and adoption of health IT infrastructure capable of supporting the transition to value-based care. The new paper targets policy changes that will improve patient data access, health data exchange and interoperability, research and health IT innovation for optimized patient care. The recommendations include improving patient access to data, patient participation in research, application programming interfaces (APIs) for interoperability, quality measure simplification and app-vetting process development. AMIA and the authors of the paper recently presented their recommendations in a briefing on Capitol Hill. “These recommendations are meant to help decision-makers understand that the idealized vision for our digitized healthcare system is within grasp,” said lead author Julia Adler-Milstein, associate professor at the University of Michigan's School of Information.

From the article of the same title
EHR Intelligence (04/06/2017)
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Nine MACRA Rules That Still Need to Be Finalized
A new whitepaper from Leavitt Partners, a healthcare intelligence firm based in Salt Lake City, discusses the U.S. Centers for Medicare and Medicaid Services’ (CMS) effort to refine the regulations of the Medicare Access and CHIP Reauthorization Act (MACRA). CMS has yet to finalize or consider adjustments for several regulations, including virtual group standards, which are a priority for U.S. Department of Health and Human Services Secretary Tom Price, according to the white paper. MACRA's virtual groups will allow rural and small practice physicians to band together for reporting purposes. On the matter of group identifiers, CMS is reviewing comments on how virtual groups would be identified for tax and billing purposes. The low-volume threshold standards would allow physicians who fall below the requirements of at least $30,000 in annual Medicare Part B charges or 100 Medicare patients to be exempt from participation in the Quality Payment Program in 2017, but as of mid-March, CMS had yet to notify clinicians of potential exemptions from the program.

From the article of the same title
Becker's Hospital Review (04/06/17) Rappleye, Emily
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States with Prescription Drug Monitoring Mandates Saw a Reduction in Opioids Prescribed to Medicaid Enrollees
Prescription drug monitoring programs are promising tools to use in addressing the prescription opioid epidemic. However, prescribers' participation in these state-run programs remained low as of 2014. A new analysis of aggregate Medicaid drug utilization data indicates that state mandates for prescriber registration or use adopted in 2011–14 were associated with a reduction of nine to 10 percent in population-adjusted numbers of Schedule II opioid prescriptions received by Medicaid enrollees and amounts of Medicaid spending on these prescriptions. This effect was largely associated with mandates of registration, which were comprehensive in all adopting states, and not with mandates of use, which were largely limited in scope or strength before 2015. The findings support the use of mandates of registration in prescription drug monitoring programs as an effective and relatively low-cost policy.

From the article of the same title
Health Affairs (Spring 2017) Vol. 36, No. 4, P. 733 Wen, Hefei; Schackman, Bruce R.; Aden, Brandon; et al.
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Medicine, Drugs and Devices

A Systematic Review and Meta-Analysis of Platelet-Rich Plasma Versus Corticosteroid Injections for Plantar Fasciopathy
New research seeks to determine whether platelet-rich plasma (PRP) injections are associated with improved pain and function scores when compared with corticosteroid injections for plantar fasciopathy. Researchers performed a systematic review of published literature for studies comparing PRP injections and corticosteroid injections for plantar fasciopathy. They included 10 studies totaling 517 patients. No studies reported adverse event rates or cost analysis. At three months, PRP showed improved pain and function scores, relative to corticosteroids. There was no difference in pain or function score at one-, six- or 12-month follow-up. Sensitivity analyses of high-quality studies showed no differences between the PRP and steroid group at any of the follow-up points. The researchers conclude that PRP injections are associated with improved pain and function scores at three-month follow-up when compared with corticosteroid injections. They also point out the lack of information regarding relative adverse event rates and cost implications.

From the article of the same title
International Orthopaedics (04/10/17) Singh, Prashant; Madanipour, Suroosh; Bhamra, Jagmeet S.; et al.
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Antibiotic Use and Kirschner Wire Fixation in Forefoot Surgery: A National Survey
New research assesses national trends regarding the use of postoperative prophylactic antibiotic therapy in patients undergoing foot and ankle surgery treated with percutaneous Kirschner wires. Researchers mailed attending physicians at foot and ankle fellowships a questionnaire that included three clinical vignettes regarding the use of postoperative antibiotics in patients treated with percutaneous Kirschner wires. In the first case of a patient without diabetes, 16 physicians (25 percent) indicated they would place the patient on postoperative antibiotics for an average of 9.4 days with an average duration of Kirschner wire fixation of 35.1 days. In the second case of a nonneuropathic patient living with diabetes, 18 surgeons (28 percent) indicated they would place the patient on postoperative antibiotics for an average of 13.8 days with an average duration of Kirschner wire fixation of 35.4 days. In the third case of a patient living with diabetes and neuropathy, 19 physicians (32 percent) indicated they would place the patient on postoperative antibiotics for an average of 14.5 days with an average duration of Kirschner wire fixation of 36.7 days. Few attending physicians placed their patients on postoperative antibiotic prophylaxis, even in patients living with diabetes for whom an increased risk of infection has been documented. The findings reflect the lack of support in the literature and lack of existing guidelines recommending for or against the use of prophylactic antibiotic therapy in foot and ankle patients treated with percutaneous pins.

From the article of the same title
Healio (04/11/2017) Pace, Gregory; Dellenbaugh, Samuel; Stapinski, Brian; et al.
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Effect of Cadexomer Iodine on the Microbial Load and Diversity of Chronic Nonhealing Diabetic Foot Ulcers Complicated by Biofilm In Vivo
New research examines the performance of cadexomer iodine against microbial populations from chronic nonhealing diabetic foot ulcers (DFUs) complicated by biofilm in vivo. Researchers recruited 17 patients over a six-month period. They used DNA sequencing and real-time quantitative PCR to determine the microbial load and diversity of tissue punch biopsies obtained pretreatment and posttreatment and used zymography to determine levels of wound proteases. Scanning electron microscopy and fluorescence in situ hybridization confirmed the presence or absence of biofilm. Eleven participants exhibited log10 reductions in microbial load after treatment (range 1–2 log10) in comparison with six patients who experienced <1 log10 reduction (P=0.04). Reductions in the microbial load correlated to reductions in wound proteases pretreatment and posttreatment (P=0.03). The team believes the study represents the first in vivo evidence, employing a range of molecular and microscopy techniques, of the ability of cadexomer iodine to reduce the microbial load of chronic nonhealing DFUs complicated by biofilm.

From the article of the same title
Journal of Antimicrobial Chemotherapy (04/10/17) Malone, M.; Johani, K.; Jensen, S.O.; et al.
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This Week @ ACFAS
Content Reviewers

Mark A. Birmingham, DPM, FACFAS

Daniel C. Jupiter, PhD

Gregory P. Still, DPM, FACFAS

Jakob C. Thorud, DPM, MS, AACFAS

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This Week @ ACFAS is a weekly executive summary of noteworthy articles distributed to ACFAS members. Portions of This Week are derived from a wide variety of news sources. Unless specifically stated otherwise, the content does not necessarily reflect the views of ACFAS and does not imply endorsement of any view, product or service by ACFAS.

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