News From ACFAS

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How does an organization like ACFAS spell success?

V – Valued
O – Optimistic
L – Loyal
U – United
N – Noble
T – Trustworthy
E – Energetic
E – Enthusiastic
R – Reliable
S – Strong

In honor of National Volunteer Week, the College thanks you, our volunteer members, for lending your time, expertise and voice to advance the profession and inspire change. Your commitment to your colleagues and patients exemplifies the spirit of service we recognize this week and appreciate year round. Own ACFAS’ popular e-Book, Arthroscopy of the Foot and Ankle, which combines the knowledge of the profession’s most renowned arthroscopists with vivid images and videos to give you a comprehensive overview of this progressive surgical procedure. Sixteen chapters filled with real cases take you through the latest arthroscopic techniques, while built-in notetaking and bookmarking tools help you keep track of your reading. Self-assessments are included after each chapter to help you earn CME.

Visit acfas.org to purchase Arthroscopy of the Foot and Ankle or the newly released The Art and Science of Orthobiologics for the Foot and Ankle and watch for updates on other e-Books in the works. If you are a fellowship program director and would like to seek status with ACFAS, submit your application by May 1, 2017.

The ACFAS Fellowship Committee will meet in mid-August in Chicago to review any new applications and will communicate their decisions later that month.

Contact Michelle Kennedy, ACFAS membership director, to request an application or to learn more about the College's Recognized Fellowship Initiative. This month’s Scientific Literature Reviews (SLRs) are now available. Catch up on the latest research compiled by podiatric surgical residents. Read this month’s SLRs for short summaries of articles from prominent medical journals at any time. New SLRs are posted each month at acfas.org/SLR to give you a snapshot of scientific studies that may affect your surgical cases.

Visit acfas.org/SLR to read the April reviews or to browse the SLR archive for studies dating back to 2009.

Foot and Ankle Surgery

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New research examines whether simultaneous surgery of the medial collateral ligament (MCL) and lateral collateral ligament (LCL) can be effectively used to treat chronic combined MCL and LCL injuries. Surgical outcomes were evaluated in 29 consecutive patients presenting with chronic MCL and LCL injuries (30 ankles; 15 men and 14 women; mean age, 31 years; 13 competitive and 10 recreational athletes). There was a significant change between preoperative and postoperative Karlsson scores and JSSF scores. On varus and valgus stress radiography, the postoperative talar tilt angle was significantly lower than the preoperative angle. Postoperative anterior displacement on stress radiography was significantly lower than preoperative anterior displacement. The researchers concluded that MCL construction or resection of medial impingement lesions, performed in addition to LCL reconstruction, is effective for treating chronic combined MCL and LCL injuries of the ankle.


New research examines compliance with weightbearing recommendations after operative fracture treatment. Researchers placed a continuously measuring pedobarography insole in patients' shoes during the immediate postoperative aftercare after ankle, tibial shaft and intertrochanteric femur fractures. Weightbearing was ordered as per the institutional standard and controlled by physical therapy. Overall, there were 30 participants in the study. Fourteen (47 percent) were considered compliant to the weightbearing recommendations, and within two weeks after surgery, patients deviated from the recommendation by more than 50 percent. Sex, age and weight did not influence the performance. Ankle fracture patients (partial weightbearing) showed a significantly increased deviation from the recommendation. The researchers concluded that despite physical therapy training, compliance to weightbearing recommendations was poor.

Practice Management

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Technology is making it easier for physicians to collaborate on care, but improper use can lead to Health Insurance Portability and Accountability Act (HIPAA) violations. Physicians must safeguard devices, such as smart phones, as well as consider each unencrypted text message, document or photograph that contains personal health information as a potential HIPAA violation, subject to a fine between $100 and $50,000 per incident depending on the severity of the violation, up to a yearly maximum of $1.5 million. Any potential HIPAA solution must address the needs of not only physicians and their staff, but also their business associates. According to a survey from Spyglass Consulting Group, only three in 10 physicians believe hospital IT is making sufficient investment to address the point-of-care mobile computing communication needs of caregivers. Reasons cited include poor mobile EHR tools, lack of planned investments and insufficient mobile user support. For all but the largest providers, virtual private networks can be difficult to set up and tricky to operate. A better solution may be the cloud where data is maintained and transmitted securely. A handful of forward-thinking secure messaging providers are making it easier for care teams to collaborate in a secure environment and to experience the benefits of connected healthcare.


Patients are employing wearable devices to record their own healthcare data, and the number of patients doing so should increase significantly, according to the Smart Wearables in Healthcare, 2016–2030 report from Research and Markets. The majority of wearables patients use are activity/fitness trackers, but the study found that companies are increasingly focused on more advanced devices that generate data ranging from electrocardiogram results to blood pressure readings to blood glucose numbers. Research and Markets also forecast that the overall market for smart wearables within healthcare will expand at an annualized rate of 13.6 percent over the next 15 years. Increasing numbers of patients are able—and sometimes keen—to share the health-related data produced by activity trackers, digital glucose monitors, digital asthma inhalers and other wearables, notes John Sharp with the Personal Connected Health Alliance. He and other experts say wearables can help enhance healthcare outcomes, especially for physicians working with patients trying to control chronic conditions. Physicians who receive data, such as blood sugar and blood pressure readings monitored by wearables between visits, can better ascertain patients' progress. This is critical as the United States migrates to value-based care reimbursement. Experts note patient-generated data can help physicians better target treatments that produce better outcomes. Sharp acknowledges gaining such benefits is challenging because data from wearables usually does not flow seamlessly into electronic health record (EHR) systems. Even if it does, it typically is not in a format usable to physicians. "Where it will work best is when the data is presented in a dashboard format that's easy for the physician to read and also when they can get alerts if something is out of whack," Sharp says.


A report by Alison Rein, senior director at AcademyHealth, says that small medical practices can play an important part in improving the health of the communities in which they are located. Rein used the example of a small practice doctor who treats several patients from the same housing area. She says these doctors are capable of detecting larger problems within that community. For example, mold and moisture problems in some housing can lead to throat and breathing problems. Furthermore, Rein says if doctors ask certain questions, they can easily determine the reasons why patients are unable to get their medication. That issue can sometimes be associated with costs or lack of transportation to a pharmacy.

Health Policy and Reimbursement

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Hundreds of U.S. hospitals are trying to cope with an unexpected consequence of the Affordable Care Act of 2010: millions more Americans have health insurance, but it requires them to spend thousands of dollars before their insurer kicks in a dime. Since the hospitals do not want to end up footing the bill, they are now experimenting with prepayment strategies for patients, with a growing number requiring payment before scheduled care and offering no-interest loans. “Most patients are appreciative that we're telling them up front,” says David Muhs, chief financial officer for the Henry County Health Center in Iowa, which provides a discount for early payment. The discussion leads some patients to skip care, delay it or use a no-interest loan available through the hospital, adds Muhs. If President Donald Trump dismantles Obamacare as promised, the Obamacare plans or employer-based health plans with low monthly payments that people are choosing for insurance will not disappear. Republicans also believe high-deductible plans curb spending, and Americans faced with medical costs that rise faster than inflation and wages will look for premiums they can afford. The trend is expected to accelerate this year because unpaid bills are creating massive bad debt for even the most prestigious medical centers.


The U.S. Centers for Medicare and Medicaid Services (CMS) has updated its payment policies for inpatient and long-term care, proposing to reduce clinical quality measure reporting requirements for hospitals that have deployed electronic health records. In addition, the agency is proposing a 12-month moratorium on the payment policy threshold for patient admissions in long-term care facilities while it continues to assess long-term care hospital policies. CMS says the goals of these provisions are to relieve providers of administrative hardship, support the patient-physician relationship and encourage transparency, flexibility and innovation in care delivery. "Medicare is better able to support the work of dedicated hospitals and clinicians who provide the care that people need with these more flexible and simplified approaches," says CMS Administrator Seema Verma. The agency forecasts hospitals would experience an increase in inpatient operating prospective payments of 2.9 percent in fiscal year 2018. Moreover, based on the revisions included in the proposed rule, payments to long-term care hospitals are expected to decline by about 3.75 percent in fiscal year 2018.


Health insurers, facing fast-approaching deadlines to file plans for next year’s Affordable Care Act marketplaces amid uncertainty about the law’s fate, are putting off key business decisions as they scour for clues on social media and in the hallways of Washington. A group of insurers met with Trump administration officials, seeking reassurance and greater clarity about the future of the exchanges. Some companies have just weeks to file proposed 2018 rates with state regulators. Insurers say continuing uncertainty will force more cautious strategies, such as bigger rate increases, or pullbacks or withdrawals, because they can no longer stomach the risk.

Medicine, Drugs and Devices

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A House Republican bill drafted as part of their plan to replace the Affordable Care Act (ACA) would make it more difficult to win lawsuits for injuries caused by medical malpractice or defective drugs or medical devices. The bill would impose new limits on lawsuits involving care covered by Medicare, Medicaid or private health insurance subsidized by the ACA and would apply to some product liability claims, as well as to medical malpractice lawsuits involving doctors, hospitals and nursing homes. The malpractice limits would lower health costs, increase access to care and save taxpayers billions of dollars, says Rep. Robert W. Goodlatte (R-Va.), chair of the U.S. House Judiciary Committee. According to the nonpartisan Congressional Budget Office, the bill would reduce federal budget deficits by almost $50 billion over 10 years. Doctors would slightly decrease the use of diagnostic tests and other services that they perform to reduce their exposure to lawsuits. Such "defensive medicine" adds to the cost of care, according to doctors. The American Medical Association, the American Hospital Association and the American Health Care Association support the bill.


The 11-member Substance Use Treatment Task Force plans to examine what practices and guidelines rehab clinics across the United States are using and then draft a plan to ensure that state agencies and insurers require clinics to use the methods deemed most effective by clinical evidence as a condition of licensing and payment. The task force includes Penny Mills, chief executive of the American Society of Addiction Medicine; Michael Botticelli, executive director of Boston's Grayken Center for Addiction Medicine and former director of the White House's Office of National Drug Control Policy; Jay Butler, chief medical officer at Alaska's health department; and officials from insurers Cigna and UnitedHealth Group. The task force aims to help reduce the number of opioid and other prescription drug deaths, which are at all-time highs across the United States. Many addicts and their families express frustration with the available treatment options, saying they are often too expensive, not covered by insurance or fail to produce long-term results. One option the task force may consider is requiring all rehab centers to report their medication policies to state authorities, and the states could then check that clinics offer or allow buprenorphine or other opioid-treatment medications before issuing or renewing licenses. Requiring clinics to report their patient outcomes to a central authority would be another useful step that would help patients and insurers know the best centers to give their business to, says Linda Rosenberg, chief executive of the National Council for Behavioral Health. Mandatory reporting of clinic practices and patient outcomes would allow insurers to pay more to centers that have "higher-quality outcomes," says Doug Nemecek, chief medical officer for the behavioral health business at Cigna, which is on the task force.


New research assesses the incidence of chronic persistent rheumatoid arthritis (RA) in a population-based cohort of twins to determine the impact of smoking. In a historical cohort study on twins born between 1920 and 1982, researchers identified 157 cases of RA among 45,280 responders (response rate 80 percent). Researchers used questionnaires and conducted interviews to obtain information on smoking and also used a mixed-effects Poisson regression model to estimate incidence rate ratios with age, sex, smoking duration and smoking intensity as covariates. They found the annual incidence of chronic persistent RA was 18.8 per 100,000 person-years, ages 15–73 years (females 25.2, males 12.0), increasing with age to a maximum at age 60 years in females and age 70 years in males. The incidence rate ratio among ever-smoking patients was 1.96 (95 percent confidence interval) 1.43–3.76), 1.93 (95 percent CI 1.00–3.7) after 30 pack-years and 1.034 (P < 0.001) per year of smoking, implying a doubling of risk after 20 years regardless of sex and smoking intensity. The team did not detect significant period or cohort effects.


Users of opioids or antidepressants who suffer from lower-extremity osteoarthritis (OA) face a greater hazard of repeated falls, according to a report published in Osteoarthritis and Cartilage. The researchers examined 4,231 individuals from the Osteoarthritis Initiative (OAI), comprising 58.4 percent women with an average age of 61.3 to 70.5 years and an average body mass index of 28.5 to 33.3. The team monitored participants' analgesic and nutraceutical use for three years and recurrent falls for four years. During the 36-month period, opioid use rose from 2.7 percent to 3.6 percent, while use of other prescription pain medicines declined from 16.7 percent to 11.9 percent. The authors determined opioid or antidepressant users had significantly higher rates of recurrent falls in the following year. Specifically, persons with knee OA who used opioids had a 22 percent higher risk of recurrent falls in the following year, versus individuals who were not taking any analgesics. "Our findings were generally consistent with prior reports that suggest opioids and antidepressants increase risk for falls in older adults," the authors note. "Clinical management of OA pain with opioids or antidepressants in older patients at risk of falls warrants caution."