News From ACFAS

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Spring your patients into the warm weather with the latest edition of ACFAS’ free FootNotes Patient newsletter!

This customizable patient education newsletter is ready for downloading at acfas.org/marketing and includes the following stories:

• Women Runners Take Fashion Warning
• Bare Feet and Summer: Not the Safest Mix
• Warm Weather Walking Checklist

The marketing opportunities are endless with FootNotes -- put them in your waiting room, use on your social media outlets, mail to your patients in their statements, use on your website or hand out at health fairs or speaking engagements. Plus, don't forget to also take advantage of other valuable marketing tools to promote your practice from ACFAS on our website in the ACFAS Marketing Toolbox. New dates and locations are set for bringing ACFAS education to you with Advanced Forefoot Reconstruction and Complications Workshop and Seminar.

This convenient and local program offers practicing and in-training surgeons the opportunity to enhance learning skills and advance their current knowledge of surgical practice.

Save the date on your calendar for the location closest to you and watch acfas.org and This Week@ACFAS for upcoming registration details.

• Division 2 – September 19-20, 2014 – Spokane, WA
• Division 12 – October 3-4, 2014 – State College, PA
• Division 4 – November 14-15, 2014 – Salt Lake City, UT
• Division 13 – December 5-6, 2014 – Columbus, OH
• Division 10 – April 24-25, 2015 – Buffalo, NY
• Division 8 – May 1-2, 2015 Portsmouth, NH

Foot and Ankle Surgery

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A new study has found that use of tibia and talus patient-specific guides created with the help of computed tomography (CT) scans can help ensure reliable and reproducible placement of total ankle arthroplasty (TAA) implants as well as patient-specific ankle alignment. Researchers created the guides by first performing CT scans on the ankles of 15 cadaveric ankles. The scans were then converted into 3D solid models and imported into a computer-assisted design assembly. Researchers then created anatomic landmarks that defined tibia/talus alignment, and used them to perform a virtual TAA. In addition, operative guides that referenced the cadaver-specific anatomy was created to define the resection planes that were needed to re-evaluate virtual placement of traditional tibia and talus implants in the post-operative position. These operative guides were then placed onto the bones by orthopaedic surgeons, who used tactile and visual feedback to determine the proper placement. This process was repeated four times to determine variability. The final position of the implant was recorded using an infrared probe, confirmed with CT scans, and compared to the pre-operative plan. Researchers found that the difference between the final implant placement and the pre-operative plan was less than two degrees in all rotational and translational degrees of freedom, compared to a difference of three degrees when traditional instrumentation and computer navigation were used with other implant systems.


The optimal location for placing syndesmotic screws on the ankle is 30 mm to 40 mm above the tibiotalar joint, as placing the screws in this location results in the greatest minimization of stress on the screws and widening of the syndesmosis under loading, a new study has found. Researchers came to that conclusion by testing six fixation configurations of the syndesmosis by placing 3.5 mm or 4.5 mm single tricortical screws at 20 mm to 45 mm from the tibiotalar joint on a 3D ankle model. The researchers then applied physiological loads to the model that were similar to those that occur during midstance and heel-off states of stance phase of normal walking in order to evaluate the stress that was placed on the screw and widening of the syndesmosis. The study found that the lowest von Mises stress on the screws occurred when they were placed 30 mm to 340 mm above the joint line. For the fixation configuration using the 3.5 mm cortical screw, the smallest amount of syndesmosis widening during the midstance phase occurred when the screw was placed 30 mm above the tibial plafond. Midstance phase testing of the 4.5 mm screw, meanwhile, showed that the smallest amount of syndesmosis widening occurred when the screw was placed 20 mm, 25 mm, or 30 mm above the tibial plafond.

Practice Management

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Physicians' practices face a number of challenges, including the economy and the decline in reimbursements, that directly affect their staff members. According to a recent survey of 1,400 doctors and practice administrators, 75 percent of respondents said they were unable to give their employees significant raises, often because of decreasing reimbursements and the national economic situation. As a result, some practices are turning to other means to reward their employees. For instance, some practice managers are providing employees with training on important issues, such as the transition to ICD-10. Still others are focusing on recognizing employees when they do a good job. Practices that are able to provide employees with financial incentives such as quarterly bonuses are choosing to provide those awards only when certain practice metrics are achieved. Meanwhile, doctors' practices face uncertainty on a number of fronts, including whether or not the implementation of the Affordable Care Act will result in an influx of new patients. Some practices have held off on hiring new staff members to prepare for such an increase, as large numbers of new patients have failed to materialize in some cases. A third challenge, the shortage of physicians, has forced some practices to turn to non-physician providers such as nurse practitioners and physician assistants (PAs) for help. Proponents of the use of PAs say they can help increase a practice's income.


Physicians' practices need to take steps to protect themselves and their patients from attacks that exploit the Heartbleed vulnerability, which could compromise the security of some electronic health record (EHR) systems, patient portals, and networked computers, says Lee Kim, JD, FHIMSS of the Healthcare Information and Management Systems Society. Kim says the vulnerability is worrisome because it could be exploited to decrypt secure Internet traffic. Some implementations of OpenSSL, the software that contains the vulnerability, have already been patched. However, Kim says that practices should be sure to contact the vendors of their web-based EHRs to see if they have indeed patched these systems if necessary. Practices that discover that their vendors have not patched Heartbleed in their web-based EHRs should ask what plan the company has in place for addressing the vulnerability, Kim says. Kim also urges practices not to forget about networked computers in their offices, which also may be vulnerable to attacks that exploit the Heartbleed vulnerability. Vulnerability scans should be performed on these systems to determine if they are at risk, Kim says, adding that a patch should be applied if a vulnerable version of OpenSSL is being used. Finally, Kim urges practices that were using a version of OpenSSL that contains the vulnerability to advise their patients to change their patient portal passwords.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) says that the use of ICD-10 diagnostic and procedural codes will be mandatory beginning Oct. 1, 2015, which is the earliest date possible under a law signed by President Obama last month. The compliance date is expected to be included in an interim rule that could soon be issued by the Department of Health and Human Services. That rule will also call for entities subject to the Health Insurance Portability and Accountability Act (HIPAA) to continue to use ICD-9-CM codes through Sept. 30, 2015. Meanwhile, experts remain concerned that many of the issues that prompted Congress to delay the transition to ICD-10 last month have yet to be resolved. Physicians are particularly concerned about the possibility that their claims flow could be negatively impacted by the transition. Such problems could hit small practices particularly hard because they lack the financial reserves to tide themselves over while waiting for the payments they are due, says American Academy of Family Physicians President Dr. Reid Blackwelder. Blackwelder says that true end-to-end testing of claims submission and processing under ICD-10 still needs to be performed to ensure small practices will not be negatively affected by the changeover.


The Centers for Medicare and Medicaid Services (CMS) has released a proposed rule that aims to force hospitals to be more transparent about the prices of the medical services they offer. Under the proposal, hospitals will be required to release a standard list of prices for these services. Hospitals that allow the public to access pricing data following an inquiry will be considered to have met the requirement. The proposal is an attempt to achieve the Affordable Care Act's goal of encouraging greater transparency about the prices of healthcare products and services so that consumers can be better informed when shopping around for healthcare providers. In addition to the pricing requirement, CMS' proposal also calls for reimbursement rates for general acute care hospitals and long-term care hospitals to be raised by 1.3 percent and 0.8 percent, respectively. Other provisions contained in the proposal aim to accelerate the implementation of the Affordable Care Act's value-based purchasing and hospital readmission reduction programs.


The American Board of Internal Medicine's new Maintenance of Certification (MOC) process is coming under fire from physicians, more than 10,000 of whom have signed a petition demanding that the changes to the process be rolled back. Physicians who went through the MOC process previously had to be re-certified and tested once every 10 years. While doctors will still need to be retested and re-certified every 10 years under the new process, they will also have to meet MOC requirements every two years and other requirements every five years. The doctors' petition maintains that the once-per-decade re-certification and testing is sufficient, and that the time physicians spend engaging in MOC activities takes them away from more important tasks such as caring for patients and pursuing continuing medical education. However, ABIM President and CEO Richard J. Baron, MD, MACP, argues that the changes that have taken place in the medical field, coupled with growing demands for greater transparency and accountability in healthcare, have made it necessary for doctors to interact with his organization more frequently. Baron adds that the 10-year re-certification and testing process does not sufficiently ensure that physicians are keeping up with the board's standards.


Although a number of proposals to reform the Affordable Care Act (ACA) have been made by Senate Democrats, observers say that none of them are likely to be enacted before the November mid-term elections. Among the proposals that have been made is one that would double the number of employees a business is required to have before it is eligible for tax credits that would help them pay their employees' health insurance premiums, and another that would increase the number of employees a company must have to in order to obtain an exemption to the employer mandate. There are several reasons why these and other proposals are likely to go nowhere before the mid-terms, observers say, including the fact that Senate Majority Leader Harry Reid (D-Nev.) has not indicated whether or not he will bring the proposals to the floor for a vote before the election. The Obama administration has also not shown an appetite for reform of the ACA, while other congressional Democrats no longer feel a sense of urgency to modify the healthcare reform law due to the growing perception that it is working at least somewhat. The reform proposals could be difficult to pass even after November, observers say, since congressional Republicans are largely focused on simply repealing the ACA.


There are concerns that consumers could face rising insurance premiums and other negative impacts resulting from the failure to fully complete a number of Healthcare.gov's back-end functions. The back-end functions that have yet to be completed play an important part in the federal government's process for paying insurance companies. The interim accounting process that is currently being used will not be replaced with a permanent process until September. Some observers, including healthcare insurance industry consultant Robert Laszewski, say that once the permanent accounting process is put in place, there could be major revisions to the payments that have been made to insurers that could prompt them to raise their rates. Health finance expert Stephen Parente agrees, adding that the revisions could prompt insurers to conclude that they have been cheated by the interim accounting process and that it is in their best interest not to participate in the exchanges, which he said in turn could cause premiums to rise substantially in 2016. Centers for Medicare and Medicaid Services (CMS) Administrator has said all of the back-end functions will be completed by this summer.

Medicine, Drugs and Devices

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A study published in the Journal of the American Medical Association has found that the prevalence of both Type 1 and Type 2 diabetes among children increased between 2001 and 2009, though researchers say they are unsure why. The study examined data on millions of children, and found that there were 1.93 cases of Type 1 diabetes per 1,000 children under the age of 19 in 2009, an increase of 30 percent since 2001. The rate of prevalence for Type 2 diabetes was 0.34 cases per 1,000 children between the ages of 10 and 19 in 2009, an increase of 35 percent from the prevalence rate recorded in 2001. Children of all racial groups, with the exception of Native Americans, had higher rates of diabetes in 2009 than they did in 2001, the report found. Study co-author Dr. Dana Dabelea said that while it is unknown what factors were behind the increase, it is unlikely that the findings were caused by improved diagnosis of diabetes.


The combination of the mammalian target of rapamycin (mTOR)-inhibitor temsirolimus and either cisplatin or bevacizumab could potentially be two promising forms of treatment for osteosarcoma and other types of cancer, though further studies are needed, a new study has found. Researchers created human osteosarcoma xenografts (OS-33 and OS-1) in vivo and tested the combinations to see what effect they had on the tumors. They found that the activity of temsirolimus in both the OS-33 and OS-1 models was significantly enhanced by adding cisplatin or bevacizumab. In addition, both combinations had an effect on tumor architecture, vasculature, apoptosis, and the mTOR-pathway.


A recent study compared the effectiveness of in-shoe orthoses designed based on shape and barefoot plantar pressure to standard-of-care A5513 orthoses in reducing the incidence of submetatarsal head plantar ulcers. The study's 130 participants were diabetics, peripheral neuropathy patients, and those with a history of similar ulcers who wore one of the two types of orthoses and were followed for 15 months. Researchers observed a trend in the composite primary endpoint (both forefoot plantar ulcers and non-ulcerative plantar forefoot lesions) in favor of the experimental orthoses throughout the follow-up period. This trend was attributed to the fact that patients who wore the experimental orthoses had a significantly lower rate of ulcer occurrence than patients who wore standard-of-care orthoses. However, there was no difference between the two groups of patients in terms of the rate of non-ulcerative lesions.