News From ACFAS

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Looking for fresh takes on the history of arthroscopy or how to best use orthobiologics to improve healing? The College’s e-Books, Arthroscopy of the Foot and Ankle and The Art and Science of Orthobiologics for the Foot and Ankle, can help. Through vivid, full-color images and step-by-step videos that put you right in the OR, these e-Books guide you through the latest surgical procedures while sharing expert insights from renowned foot and ankle surgeons.

These e-Books feature built-in notetaking and bookmarking tools to help you keep track of your reading and also include self-assessments after each chapter that allow you to earn CME credit.

Visit acfas.org/e-learning now to purchase the e-Books, and watch ACFAS publications for updates on new e-Book releases. Hear a panel of your colleagues weigh in on arthroscopic intervention in trauma patients in the April podcast, “Arthroscopy Assisted ORIF.” Learn how to improve outcomes in reduced fractures and the best ways to put these new strategies to use in your own practice.

ACFAS’ complete podcast library is always just a click away at acfas.org/e-Learning. New releases are added monthly, so visit often to stay up to date on the latest topics and trends gaining a foothold in the profession. The Mirmiran Scholarship opportunity rotates to a different campus every year. For 2019, students from NYCPM will be recognized. AZPod: Kyleigh Pierson, Class of 2021

Great Lakes Region:
Kent State: Natasha Bhagat, Class of 2020

Midwest Region:
DMU: Robert Clements, Class of 2020
Scholl: Daniel Ryan, Class of 2020

Northeast Region:
NYCPM: Jonathan Shalot, Class of 2020

Pacific Region:
CSPM: Varsha Salunkhe, Class of 2020
Western U: Brittany Mammano, Class of 2019

Southeast Region:
Barry: Misha Tavaf, Class of 2020

Tri-State Region:
Temple: Stephanie Golding, Class of 2020

Foot and Ankle Surgery

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The primary objective of this study was to investigate the diagnostic value of dynamic contrast-enhanced MRI (DCE-MRI) in differentiating osteomyelitis from acute neuropathic arthropathy in the diabetic foot. The prospective study was carried out on 30 diabetic foot patients, with a mean age of 51 years. The patients all underwent clinical examinations, laboratory examinations and DCE-MRI. The DCE-MRI parameters (Ktrans, Kep and Ve) of the regions of acute neuropathic arthropathy and osteomyelitis were calculated. Receiver operating characteristic curves (ROCs) were used to identify the DCE-MRI parameters that showed the highest accuracy in differentiating the acute neuropathic arthropathy from the osteomyelitic regions. Pearson correlation coefficients were used to assess the correlations among the DCE-MRI parameters, the level of C-reactive protein (CRP) and the erythrocyte sedimentation rate (ESR). The Ktrans, Kep and Ve values of the osteomyelitic regions were higher than those of the acute neuropathic arthropathy regions, and significant differences were found between the two groups. The ROC analysis showed that Ktrans and Ve performed best in differentiating osteomyelitis from acute neuropathic arthropathy, both with an area under the curve of 0.938. The Pearson correlation coefficients showed that the DCE-MRI parameters correlated significantly with the level of CRP and ESR. The results indicate that DCE-MRI may provide reproducible parameters that can reliably differentiate osteomyelitis from acute neuropathic arthropathy.


In this study, researchers sought to present results and complications in a case series of outpatients with diabetic and neuropathic foot ulcers with exposed bone, following surgical debridement treated with negative-pressure wound therapy (NPWT). Retrospective data was obtained from digital medical records from the Maccabi Health Services High Risk Foot Clinic in Tel Aviv, Israel, between 2009 and 2014. Medical records examined were those of clinic outpatients with exposed bone following partial foot amputation or selective bone debridement (University of Texas grade III-A) treated with NPWT. Sixty-six patients received NPWT in a total of 77 treatment courses. Mean patient age was 62 ± 10 years, 82 percent were male and mean diabetes mellitus duration was 14 ± 8 years. Mean HbA1C levels were 8.1 percent ± 1.7 percent. Mean treatment course duration was 16 days (range, 2–42 days). Wound area decreased significantly (from 11.3 ± 16.8 cm to 8.0 ± 13.3 cm, P < .0001). Ulcer curing was noted in 7 percent of the cases, and healing progression was noted in 54 percent. Seven serious adverse events were recorded. The researchers concluded that outpatient NPWT is a relatively safe and effective adjuvant to surgical debridement of neuropathic foot ulcers. In an outpatient setting, one can expect serious adverse events to occur in 10 percent of cases, but this seems unavoidable in patients with diabetic foot ulcers when taking into account their comorbidities and patient resources. Strict protocols to promote early recognition of complications and appropriate response to minimize deterioration must be implemented.


A study was conducted to explore parameters contributing to preoperative pain intensity in patients with osteochondral lesions of the ankle. The assessment involved patient-related parameters, such as age, sex and body mass index (BMI), along with defect-related parameters, such as localization, size and stage. Researchers also evaluated the correlation between the different surgical methods and factors, such as debridement of an impingement or stabilization of the ankle and preoperative pain intensity. The average preoperative pain intensity in the complete study cohort was 3, and no correlation between the age and the preoperative pain intensity was seen. No difference was observed between the two genders in terms of preoperative pain intensity, while a higher BMI was correlated with a higher preoperative pain intensity in female patients. There was no observed difference between the different localizations of the defect in the cohort with a solitary treated talus lesion, in terms of preoperative pain intensity. The defective area was not correlated with the lesion stage according to the International Cartilage Repair Society classification or with the preoperative pain intensity in the cohort with a solitary treated talus or tibia lesion. A higher lesion stage was correlated with a higher preoperative pain intensity, based on the Berndt-Harty-Loomer classification.

Practice Management

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Among the most common billing errors physician practices make are those caused by typos, and the American Academy of Family Physicians' Brennan Cantrell says the best solution "is having an employee dedicated to watching for and correcting these errors. For small practices, this may not be a full-time employee, and the time saved by not having to resubmit claims might offset the time spent rooting out mistakes." A second reason is the practice not sending enough information in the claim, and Tammie Olson of the Management Resource Group recommends making sure to submit documentation with the claim when it is filed. Another frequent mistake is not getting prior authorization when required. "If it is, send in the request before scheduling the procedure," Olson advises. Furthermore, the practice should request the patient's insurance card during every visit to see whether coverage has been terminated or whether payers or plans have changed. Finally, smaller practices may need to make sure the front desk or billing staff carefully reviews payer policy bulletins as soon as they are issued, to avoid mistakes.


Finding the right telemedicine vendor can be challenging, as it requires considering both the big picture and the small details. Determining the objectives for implementing telemedicine is paramount, and they can include positioning the practice as innovative and transformative, staying competitive in a market where other companies advertise often about their own telemedicine capabilities and developing a multiyear strategy for entering the digital health domain. Once a practice understands why it wants to deploy telemedicine, finding a third-party planner can help it choose potential vendors. A branded website can also be an important consideration, but among its drawbacks is patients associating a bad platform experience with the practice. Practices that rely on smartphone apps to connect with patients should query whether the vendor is able to support patients who use both iPhones and Android devices. Getting feedback from patients on how telemedicine should work is also essential, and one expert suggests that practices should ask vendors for a 30-day trial period to ensure that they can truly provide the services they claim to offer. In addition, when a vendor offers customer support, it needs to guarantee it is available during extended hours or over the weekend.


Sharon Quinlan, the vice president/chief nursing officer of ambulatory care at Advocate Aurora Health, shares her insights on enhancing patient experience through patient- and family-centered care. Quinlan's passion for patient experience came from her personal dealings with the healthcare system when, in quick succession, both of her parents experienced complex, multiple chronic disease conditions and ultimately died. Even as a healthcare professional, she found that navigating the system was a challenge and communication was subpar. "The healthcare system was helping us achieve our clinical outcomes but wasn't helping us with the burden of illness," says Quinlan. "It really changed the way I thought about my practice and my leadership." She has four suggestions to promote partnerships between patients and organizations. First, expand your view of what patient experience is. She recommends that organizations consider consumer value, patient-centered care and what that can lead to, "as opposed to just focusing on patient satisfaction, patient experience and HCAHPS or CGCAHPS scores." Second, be an intentional listener and engage patients as partners. One way to do this is by forming patient advisory councils, she says, which "will help caregivers understand the [heart] of the patient's experience and how we might specifically design any program." Third, drive improvement through consumer research, which backs up the findings of the advisory councils. Finally, connect back to the organization's culture and deliver messaging that shows how listening to patients and understanding their perspectives is important.

Health Policy and Reimbursement

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Sales are increasing for fixed indemnity plans, a type of bare-bones health policy that is a more affordable alternative to traditional insurance but that could leave policyholders with large bills if they have major medical needs. These plans typically pay set amounts toward the cost of doctor visits, hospital stays or other services, and they generally carry restrictions on people with preexisting conditions. They are not considered true health insurance under the Affordable Care Act (ACA), but insurance agents say they increasingly are being purchased as a substitute for ACA coverage by individuals who do not receive federal subsidies. Many of the products are sold only to those who can attest to being healthy. Chubb, Anthem and UnitedHealth Group are among the carriers offering indemnity plans. According to AgileHealthInsurance.com CEO Bruce Telkamp, consumers "need affordable options. Carriers are significantly investing in this category to fill that void." Meanwhile, agents indicate that short-term insurance may become more appealing as well, with the Trump administration proposing to lift a cap limiting such plans to three months.


A new bill called the Choose Medicare Act would allow businesses and Obamacare customers to buy into Medicare. The proposal, which has 10 Democratic co-sponsors and no Republican sponsors, is a kind of "public option" that would be sold alongside the option to purchase private health insurance. It would be known as "Medicare Part E." The bill offers Medicare plans both to individuals who do not receive coverage through a job and to employers. Medicare covers adults 65 and older and people with disabilities. Under the new proposal, the same benefits would be offered, but the government would be permitted to negotiate drug prices. The Choose Medicare Act also could make government subsidies more generous than Obamacare. It would enable individuals who make up to 600 percent of the federal poverty level to receive subsidies that reduce the cost of premiums to them, compared to the current cap of 400 percent, or about $48,240 per year for an individual. Sen. Chris Murphy (D-Conn.) believes that many consumers would select Medicare rather than buy private plans and that offering Medicare would encourage private health insurers to offer more competitive prices. Other Democrats have supported a separate proposal called the Medicare for All Act, which would bring every U.S. citizen onto the Medicare program regardless of whether someone has employer coverage or is on Medicaid. Senators have framed the Choose Medicare Act as a possible, smaller step in that direction.


The Medicare Diabetes Prevention Program launched on April 1 seeks to prevent seniors and other disabled individuals from developing Type 2 diabetes, but experts say the program's road has been rough so far. They note the program is currently up and running at only few sites, and finding out where it is available is problematic. The program is freely available to older adults and people living with disabilities who have Medicare Part B coverage and prediabetes. Community organizations, such as YMCAs and senior centers, will supervise the program instead of doctors and hospitals, but many locations are grappling with Medicare's contracting mandates and are reticent to take on burdensome administration, says Brenda Schmidt with the Council for Diabetes Prevention. Although Medicare Advantage plans are now obligatory for offering the program to beneficiaries, they are not doing active outreach due to a lack of program sites. The U.S. Centers for Disease Control and Prevention's Ann Albright says patience should be exercised, as building an infrastructure of community organizations to deliver these services "hasn't been done before." Meanwhile, a U.S. Centers for Medicare and Medicaid Services spokesperson says approximately 50 of more than 400 eligible programs are currently submitting applications, while an online resource identifying approved programs is being developed and outreach to Medicare beneficiaries is "planned for the coming months."

Medicine, Drugs and Devices

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Amazon has reportedly shelved its plan to sell and distribute pharmaceutical products after considering it last year. The company is instead focused on selling less sensitive medical supplies to hospitals and smaller clinics through Amazon Business. The change in plan comes partly because Amazon has not been able to convince big hospitals to change their traditional purchasing process, which typically involves a number of middlemen and loyal relationships. In addition, some say Amazon would need to build a more sophisticated logistics network that can handle temperature-sensitive pharmaceutical products. Amazon has still not completely ruled out getting into the pharma distribution space eventually. Multiple reports have speculated that the company will someday add a direct-to-consumer prescription drug business. Amazon Business could also reconsider getting into the pharma space once it gains more scale, according to people familiar with the matter.


The 4^th Circuit Court of Appeals ruled that a Maryland law passed last year to stop sharp increases in the price of generic medicines is unconstitutional, a setback to new efforts by states to keep down the cost of drugs. The appeals court found that the law regulates trade that happens beyond Maryland's borders and so is prohibited by the so-called dormant commerce clause. Judge Stephanie Thacker wrote an opinion ordering a lower-level federal judge to bar the law from going into effect. "Maryland cannot, even in an effort to protect its consumers from skyrocketing prescription drug costs, impose its preferences in this manner," Thacker wrote. Maryland passed the legislation after reports of steep price increases for generic drugs, especially those where a small number of companies controlled the market for medicines that doctors deem essential. The law gave authorities new power to monitor price changes and to seek fines or court orders reversing increases. But the Association for Accessible Medicines, a drug industry trade group, sued the state over the law, saying it was unconstitutional. The organization has argued that the measure could hurt competition by scaring companies out of the business of making generic drugs and could actually drive up prices.


A new U.S. Food and Drug Administration (FDA) plan lists concepts and proposals for improving federal medical device oversight, targeting better safeguards on pacemakers, artificial joints, medical scanners and other products. The agency will consider requiring more training for physicians who implant high-risk devices, which may demand new guidelines or regulations. FDA also will consider additional scrutiny of devices for women, following recent problems with vaginal mesh; new ways to encourage manufacturers to enhance safety, including faster approval for devices that appear safer than what is available; and mandating cybersecurity features for electronic devices, such as implantable heart pacemakers and defibrillators. In addition, the agency will request more funding for a public-private system designed to track insurance claims, electronic health records and other data sources for early signs of device problems. The project is calculated to cost $250 million over five years to become operational and is currently slated to receive $30 million from device manufacturers.