News From ACFAS

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ACFAS’ free Podcast Library in the e-Learning Portal gives you instant access to expert panelists’ views on timely topics in foot and ankle surgery. Listen to podcasts when you’re at home, traveling or on break in between patients to stay ahead of the profession’s latest trends and advancements.

Visit the Podcast Library to hear this year’s releases and browse archived recordings. Watch for June’s podcast, “Postoperative Fracture Care,” with panelists Matthew A. Hopson, DPM, FACFAS; J. Randolph Clements, DPM, FACFAS; and Justin Fleming, DPM, FACFAS, to debut soon. ACFAS members take time to relax and recharge—at least according to the latest This Week @ ACFAS poll results. When we asked our members when was the last time they took a vacation, sixty-nine percent of responders said they have done so within the past year. Thirteen percent said they last took a vacation more than a year ago, and another 13 percent last vacationed more than five years ago. Only six percent can’t remember the last time they got away.

Thank you to all who voted! Watch for next month’s poll in the June 7 issue of This Week @ ACFAS, and view live results on acfas.org throughout the month. Register now for Officite’s free 30-minute webinar, “Social Media for Your Practice: How to Make Your Patients Like You,” scheduled for Wednesday, June 14 at 1pm (CT). Presenter Adam Barnett will teach you the dos and don’ts of marketing your practice on Facebook, Twitter and other platforms and will show you how social media can help improve your bottom line.

Learn more about Officite and our other ACFAS Benefit Partners on acfas.org.

Foot and Ankle Surgery

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Achilles tendinopathy is the most prevalent tendon disorder in people engaged in running and jumping sports and requires comprehensive research of contributing risk factors. The purpose of this systematic review was to identify studies and to summarize current knowledge of biomedical risk factors for Achilles tendinopathy in physically active people. Research databases were searched for relevant articles followed by assessment in accordance with the PRISMA statement and standards of the Cochrane collaboration. A systematic review of the literature identified 22 suitable articles. Being overweight was a risk factor described in five included studies that investigated nongenetic factors. COL5A1 genetic variants were the most extensively studied, particularly in association with genetic variants in the genes involved in regulation of cell-matrix interaction in tendon and matrix homeostasis. Polymorphisms in genes involved in apoptosis and inflammation, and Achilles tendinopathy did not show strong association but should be considered for further investigation. This systematic review suggests that biomedical risk factors are an important consideration in the future study of propensity for the development of Achilles tendinopathy. The presence of certain medical comorbidities and genetic markers should be considered when contemplating the etiology of Achilles tendinopathy. The researchers concluded that further investigating biomedical risk factors will aid in the understanding of tendon pathology and patient risk.


Typical tools for evaluating foot Charcot arthropathy on radiographs include Eichenholtz and the Schon systems. However, a novel system with expanded characterization may have added benefit. Researchers grouped patients with Charcot arthropathy and foot radiographs in nonsurgical group one (imaging sets at minimum two-year interval) and surgical group two (imaging preceding fusion and/or amputation). Radiographs were scored with Eichenholtz and Schon systems and a novel scoring system (summation of zero to three rank for bone density, distention/swelling, debris, disorganization and dislocation/subluxation). A total of 111 patients were included (19 patients in group 1; 92 patients in group 2). The novel system provided a broad numerical characterization of the radiographs (range one to 15). Summative scores of the novel system for groups one and two were statistically different with lower median score in the nonsurgical group (nonsurgical median score six vs surgical median score nine). Individual characteristic scores from four (distention, debris, disorganization and dislocation) of five categories for the novel system were statistically different, with lower scores for the nonoperative group. The narrower numerical scores from the Eichenholtz and Schon systems did not yield statistically significant results. Based on these results, the researchers concluded that the novel scoring system provides a broad numerical description of radiographic findings in Charcot arthropathy of the foot and has potential advantage for surgical predictive value.


The goal of this study was to examine relationships between patients' preoperative expectations and their demographic and clinical characteristics. Researchers hypothesized that patients with more disability and those with anxiety or depressive symptoms would have greater expectations. Adult patients scheduled for elective foot or ankle surgery by one of six orthopaedic foot and ankle surgeons were screened for inclusion over eight months. Preoperatively, all patients completed the Hospital for Special Surgery Foot & Ankle Surgery Expectations Survey in addition to the Foot & Ankle Outcome Score, Short Form-12, Patient Health Questionnaire-8, Generalized Anxiety Disorder 7-item scale and pain visual analog scale (VAS). The expectations survey contained 23 expectations categories, each with five answer choices ranging from "I do not have this expectation" to "complete improvement." The researchers found that expectations scores were not related to age, and on average, women expected to achieve complete improvement more often than men. Variables that were significantly associated with higher expectations scores included nonwhite race, use of a cane or other assistive device and greater medical comorbidity. Worse function and quality of life, more depressive and anxiety symptoms, and higher pain VAS scores were associated with higher expectations scores and more expectations. The researchers concluded that generally, patients with worse function and more disability had higher expectations from surgery. Addressing these patients' expectations preoperatively may help improve their ultimate satisfaction with surgery.

Practice Management

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Allowing students or medical residents to shadow or to do a rotation in a physician's practice is not as time-consuming as it may appear. To avoid disrupting their schedule, it is important that physicians are aware of the student's capabilities. This can include whether they know how to take a history and physical. Some are not as proficient as others, so knowing their current skillset can help with arranging suitable tasks for them. Some students can start taking histories as soon as they step into the office, but if they are too slow, the physician can go on to the next patient while waiting. If the student does a good job, he or she will have gathered key information, saving the physician time. It is also important to trust students and not have them constantly trail after the physician. Students should have the freedom to learn at their own pace. They will eventually become accustomed to the rapid pace of medicine but should be allowed to explore what works for them. Students can also be assigned study topics, such as a rare disease, that can serve as a review for both parties. Students can also be a source of interesting cases worthy of being addressed in journals. Physicians can help students get published as well as become published themselves. A key reward is when students return years later to thank a physician for being a good mentor in their education and training.


A shift in payment responsibilities, higher deductibles for insured patients and problems with transparency across multiple systems are likely to affect how small practices collect payments from patients and health insurers, says Bird Blitch, chair of the Healthcare Information and Management Systems Society (HIMSS) Revenue Cycle Improvement Task Force. "Today, in many cases, payments make up 33 percent government, 33 percent insurance companies and 33 percent patients, which vary from practice to practice," he says. Industry stakeholders have been introducing new ideas to enhance collecting payments, such as encouraging payment at the beginning of a patient/physician encounter and finding ways to improve claim denials. "We've identified gaps across the patient payment journey, and we are looking inside the industry to see if we can come up with solutions that involve developing better processes and technology," Blitch adds. One example is forming flexible and convenient payment options that help patients pay an unexpected expense, such as an online payment portal with payment plans or financing options. Another approach is developing a unified system that incorporates reporting and analytics tools to help providers find out the underlying cause of revenue trends to enhance their revenue cycle management (RCM) system. "Providers are struggling to cope with getting their arms around the fastest growing payer, which is the patient," says Blitch.


On May 11, President Donald Trump signed Executive Order – Strengthening the Cybersecurity of Federal Networks and Critical Infrastructure. Although the order states, "federal networks and critical infrastructure," people who contract with the government, including physicians who bill Medicare, need to meet the same standards. The order states that IT and data should be properly secured, risks are known but not mitigated and various agencies and agency heads will be held accountable. The order includes three main takeaways for physicians. First, a risk assessment that includes National Institute of Standards and Technology (NIST) standards, as referenced throughout the HIPAA omnibus rule, is critical. Second, continual training of everyone in a medical practice is essential. Third, issues might arise with Medicare claims submission if these standards are not met. For example, if physicians do not comply with HIPAA and the HITECH Act relating to the executive order’s cybersecurity language, a potential exists for filing false claims.

Health Policy and Reimbursement

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President Trump's proposed 2018 budget entails huge cuts to Medicaid and science and biomedical research funding. Medicaid would lose $610 billion over the next 10 years, on top of the $839 billion that would already be slashed under the proposed Affordable Health Care Act. Meanwhile, the National Institutes of Health (NIH) would receive 18 percent less funding next year compared to its 2017 budget, receiving $26 billion. The National Cancer Institute would have 19 percent of its budget trimmed, while the NIH's Fogarty International Center, a program to promote medical research abroad, would be eliminated. In addition, the U.S. Centers for Disease Control and Prevention (CDC) would lose 17 percent of its budget for a total of $6.3 billion. Seventeen percent less money would be spent on HIV/AIDS, viral hepatitis, sexually transmitted infections and tuberculosis prevention, and CDC's global health program would face an 18 percent budget reduction. Furthermore, the Agency for Healthcare Research and Quality would be removed as a standalone agency, with many of its services bundled into the NIH. A prematurely released document states the budget "focuses resources on direct services and proven investments while streamlining or eliminating programs that are duplicative or have limited impact." Personalized Medicine Coalition President Edward Abrahams has condemned the budget proposal as "a travesty for patients and the future of personalized medicine if enacted."


The Congressional Budget Office (CBO) estimates the House GOP's health overhaul bill would add another 23 million uninsured Americans and cut $119 billion from the cumulative federal deficit in the next decade compared with current law. The bill's most far-reaching revision is an additional amendment allowing states to opt out of some of the Affordable Care Act's (ACA) provisions. The amendment would permit states to secure waivers that could let health insurers sell less encompassing coverage plans, while also imposing higher premiums on people with preexisting conditions and lapsed coverage. CBO determined premiums would spike by an average of about 20 percent next year and five percent the year after, versus current law. However, in 2020, average premiums would vary based on whether states gained waivers, with prices declining for many consumers. Yet CBO found although healthier people would see lower premiums, in some parts of the United States, where states opt out of some of the ACA's rules, "less healthy people would face extremely high premiums." ACA-supporting Democrats say CBO's assessment confirms that Republicans favor the affluent and the healthy over others. "Unless you're a healthy millionaire, Trumpcare is a nightmare," warns Senate Minority Leader Chuck Schumer (D-N.Y.).


Some providers are skeptical about President Donald Trump's tort reform proposal, which calls for capping medical malpractice awards for noneconomic damages at $250,000. The proposal would also establish a three-year statute of limitations for claims and exclude provider expressions of regret or apology from lawsuit evidence. The tort-related reforms outlined in the budget are estimated to save approximately $31.8 billion over 10 years. A large portion of the estimated savings stem from eliminating unnecessary services and discouraging defensive medicine, which refers to the practice of recommending a diagnostic test or medical treatment that may be unnecessary but is performed anyway to protect a physician against a malpractice suit. Dr. Jane Orient, an internist and executive director of the conservative Association of American Physicians and Surgeons, believes the administration should be providing states with more enforcement flexibility rather than dictate tort reform. Tort law falls under state purview, and at least 30 states already have some type of cap on malpractice suit damages. If Trump's tort reforms become law, a state could legally challenge the changes for overstepping their sovereignty, according to attorney Rachel Rose. Michael Stinson at PIAA, a trade group representing professional liability insurers, says federal tort reform could help address malpractice issues in telemedicine or other practices that cross state lines.

Medicine, Drugs and Devices

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U.S. Food and Drug Administration (FDA) Commissioner Scott Gottlieb is focused on curbing high prescription drug prices and accelerating time to market for generic medications. “Simply put, too many patients are priced out of the medicines they need,” Gottlieb recently told the agriculture subcommittee of the House Appropriations Committee. “While FDA does not have a direct role in drug pricing, we can take steps to facilitate entry of lower-cost alternatives to the market and increase competition.” Gottlieb's plans include agency interventions in cases where brand-name drug companies are charged with using FDA safety rules to refuse to manufacture drugs available to generic drugmakers. “FDA has an important role to play in making sure that its statutory and regulatory processes are working as intended and not being manipulated in ways that FDA and Congress did not intend,” Gottlieb told the subcommittee. The commissioner's drug price effort also includes plans to expedite generic-drug approvals by cutting the backlog of applications at FDA and to ease the market entry of generic versions of “complex” drugs. In addition, Gottlieb is urging his agency to regularly publicize lists of older drugs that still lack generic competition, in an attempt to attract generic firms into the market.


A study published in Seminars in Arthritis & Rheumatism found ultrasound administered to patients with rheumatoid arthritis in clinical remission could predict damage at 12 months. In a cohort of 42 patients, longer disease duration, higher body mass index and use of prednisone but nonuse of conventional disease-modifying antirheumatic drugs and biologics correlated with erosions after a year's follow-up. Furthermore, ultrasound-defined active synovitis was associated with progression of erosions. Synovial hypertrophy and power Doppler were each graded from zero to three, with higher scores signaling greater severity. Univariate analysis showed the presence of subclinical synovitis evaluated via either power Doppler or synovial hypertrophy was associated with erosions both at baseline and 12 months, but more erosions were observed with the more stringent hypertrophy scores than with Doppler alone. Adjusted analysis with linear models associated several baseline clinical and medication factors with progression of magnetic resonance imaging erosion scores at one year.


Sensors and actuators are increasingly being integrated with wearable devices for gait interventions to slow the progression of knee osteoarthritis. Wearable haptic gait retraining is an area that has shown promising results for informing modifications of gait parameters for reducing knee adduction moments (KAM) during walking. Gait parameters that can be easily adjusted to influence KAM are foot progression angle (FPA) and step width (SW). The purpose of this study was to determine whether a custom haptic ankle bracelet using binary vibrotactile and tactile apparent movement feedback could retrain 10 healthy subjects to walk with a modified FPA and SW within a short training session with 80 percent accuracy. Researchers also wanted to identify any differences between the number of steps required to complete the retraining task based on two feedback schemes. Retraining multiple gait parameters using a single device was a novel aspect of this work, and researchers found that nine out of 10 subjects were able to retrain their gait using the ankle bracelet in both feedback schemes to within two degrees and 39 mm of target FPA and SW, respectively. The researchers also found no difference in the number of steps required for completion between the two schemes. Future research will investigate the device performance in patients with knee osteoarthritis and the effective change in KAM obtained by modifying a combination of FPA and SW. The researchers concluded that the haptic ankle bracelet is effective in retraining foot progression angle and step width during walking.