June 6, 2018 | | JFAS | Contact Us

News From ACFAS

Win an iPhone X! Survey Responses Due June 15
The deadline for responding to the College’s triennial Member or Practice Surveys is June 15. Two respondents will win an iPhone X, and six respondents will win Bose noise-canceling earphones. Make sure your voice is heard. Search your inbox for an email from and respond ASAP. All responses are anonymous and are only reported in the aggregate by a third-party survey consultant. Survey results will be available on in late summer.
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Explore the New JFAS Website
The Journal of Foot & Ankle Surgery (JFAS) website just got a face lift! Your online resource for the latest in podiatric medical research now boasts a cleaner and more streamlined look and also features easier navigation, photo previews of articles, Journal metrics and more.

Not only is the redesigned website more secure and better aligned with the College’s brand, it now includes photo highlights from the current issue plus a featured article of the month. You can also:
  • View the current issue in full, articles in press as well as most read and most cited articles
  • Browse through the Journal archive for specific issues and supplements
  • Search the Collections to quickly find articles categorized by foot and ankle topics
  • Access guidelines and tools for authors, peer reviewers, editors and advertisers
Be sure to take advantage of a new Researcher Academy hosted by JFAS publisher Elsevier on, which provides free e-learning modules to guide you through every stage of the research process.

Visit to explore the new website or to submit your article to a future issue of JFAS.
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Three New PPTs Added to Marketing Toolbox
Head to the ACFAS Marketing Toolbox to download three brand-new, free PowerPoint presentations you can use when meeting with patients or when speaking at local health events this summer.

These latest additions to the Toolbox include:
  • Achilles Tendon Injuries
  • Flatfoot in Adults
  • Having a High Arch (Cavus Foot): Too Much of a Good Thing

Each presentation outlines condition signs and symptoms plus surgical and nonsurgical treatment options. The files also feature a customizable slide for your practice’s contact information as well as an accompanying script to keep the conversation on track.

Take advantage of the many other free resources in the Toolbox, such as the FootNotes patient newsletter, healthcare provider referral tools and press release templates, to promote your practice throughout the year. Visit regularly for new products.
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Foot and Ankle Surgery

Functional Outcomes of the Failed Plate Fixation in Distal Tibial Fractures Salvaged by Hexapod External Fixator
Researchers evaluated the clinical and functional outcomes of failed plate fixation in distal tibial fractures salvaged with hexapod circular fixators. They searched the database of a specialized limb reconstruction center for patients with failed plate fixation undergoing limb reconstruction with a circular external fixator between 2008 and 2017. Patients between the ages of 18 and 65 years, with a symptomatic distal tibial malunion or nonunion following plate and screw fixation were included. The SF-12 and Foot Function Index (FFI) scoring systems were used to measure clinical and functional outcomes.

Ten patients met the inclusion criteria. Seven patients had an infected nonunion, two had hypertrophic nonunions and one had a malunion. The mean follow-up was 41.7 ± 28.3 months. The mean duration of external fixation was 232.9 ± 146.6 days. The SF-12 demonstrated a mean score of 49.4 ± 7.7 for the physical component and a mean score of 55.3 ± 8.1 for the mental component. Five patients scored above 45 points for the SF12 physical component, and nine patients scored above 45 points for the mental component, indicating that a good outcome can be achieved. The mean FFI score was 24.9 ± 19.9, and six patients had a score below 14 points, indicating a good outcome. Radiological union was observed in all 10 patients at a mean of 29 ± 14 months.

The results of this study suggest that hexapod circular external fixation is an attractive surgical alternative for the treatment of failed plate fixation of distal tibial fractures, and it can reliably achieve bony union and result in very satisfactory clinical outcomes.

From the article of the same title
European Journal of Orthopaedic Surgery and Traumatology (05/18) Molepo, Maketo; Barnard, Annette-Christi; Birkholtz, Franz; et al.
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Strength of Suture-Button Fixation Versus Ligament Reconstruction in Syndesmotic Injury: A Biomechanical Study
In this cadaver biomechanical study, researchers compared the biomechanical characteristics of suture-button fixation with ligament reconstruction using semitendinosus tendon autograft in treatment of syndesmotic injury.

Eight matched pairs of human cadaveric lower extremities were measured intact, then followed simulated syndesmosis injury by cutting the anterior tibiofibular ligament (AITFL), the distal 15 cm of the interosseous membrane (IO) and the deltoid ligament. The syndesmotic injury was then treated by suture-button fixation or ligament reconstruction. The semitendinosus tendon was harvested as a graft. Biomechanical testing was performed after the surgical fixation. The foot underwent rotation from neutral position to an external rotation at a rate of 5°/s to 12.5 Nm. The three-dimensional syndesmotic diastasis readings, final rotation torque and rotational angle were recorded.

No difference was found in fibular displacements between the two groups. In addition, no significant difference was found in final rotation torque (11.95 ± 1.03 versus 11.66 ± 1.18 Nm, P = 0.62) and rotation angle (43.61° ± 14.77° versus 40.93° ± 10.94°, P = 0.56) in the suture-button group and ligament reconstruction group.

The researchers concluded that the stability of the suture-button fixation was equivalent to ligament reconstruction using semitendinosus tendon autograft in treatment of syndesmotic injury as determined with biomechanical testing. However, this study does not prove that one is advantageous over the other.

From the article of the same title
International Orthopaedics (05/24/18) Li, Hong-Yun; Zhou, Ru-Shou; Wu, Zi-Ying; et al.
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The Society for Vascular Surgery Wound, Ischemia and Foot Infection (WIfI) Classification System Predicts Wound Healing Better than Direct Angiosome
The aim of this study was to compare the Society for Vascular Surgery Wound, Ischemia and foot Infection (WIfI) classification versus angiosome direct perfusion (DP) and pedal arch patency as predictors of wound healing in patients presenting with diabetic foot ulcers (DFUs) and peripheral arterial disease.

The researchers conducted a retrospective review of a database of all patients with peripheral arterial disease presenting to its multidisciplinary DFU clinic who underwent angiography. Wound healing time at one year was compared on the basis of DP versus indirect perfusion, Rutherford pedal arch grade and WIfI classification using univariable statistics and Cox proportional hazards models.

Angiography was performed on 225 wounds in 99 patients during the entire study period. DP was achieved in 154 wounds and indirect perfusion in 71 wounds. On univariable analysis, WIfI classification was significantly associated with improved wound healing (57.2 percent for WIfI 3/4 versus 77.3 percent for WIfI 1/2; P = .02), whereas DP and pedal arch patency were not (both, P = .08). After adjusting for baseline patient and wound characteristics, WIfI stage remained independently predictive of wound healing, whereas DP and pedal arch grade were not.

The researchers concluded the WIfI classification system was a stronger predictor of diabetic foot wound healing than DP or pedal arch patency. The results suggest that a measure of wound severity should be included in all future studies assessing wound healing as an outcome, as differences in patients' wound characteristics may be a strong contributor to the variation of angiosome-directed perfusion results previously observed.

From the article of the same title
Journal of Vascular Surgery (05/23/18) Weaver, M. Libby; Hicks, Caitlin W.; Canner, Joseph K.; et al.
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Practice Management

Benefits Review: How to Better Your Practice
Every practice needs to find the right balance of employee benefits to keep a healthy margin. Experts say practices should review their benefits annually and survey employees before making any major changes to benefits, while also being proactive. Arthur Tacchino at Sync Stream Solutions says it may be useful to review benefits more than once a year in the current health insurance landscape. He notes that short-term or "mini" medical plans might only cover an individual for three months to 12 months.

These plans are "not real insurance" warns Jonathan Gruber, professor of economics at the Massachusetts Institute of Technology. He adds, "Employers don't need to cut benefits. Just cut out high priced providers that aren't much better than any other providers." Practices should also use available resources, such as online analysis toolkits or a financial advisor, to estimate the costs of offering different levels of benefits packages under multiple scenarios.

From the article of the same title
Physicians Practice (05/29/18) Rosenfeld, Jordan
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Curb Clinician Burnout with This Four-Point Strategy
A new report by Press Ganey advises medical staff to deconstruct burnout by categorizing stressors and rewards as inherent or external. Inherent components of burnout and resilience include the emotional drain linked to providing care to the ill and witnessing suffering, while rewards include the joy of helping people and doing meaningful work. External components of burnout and resilience include working with electronic health record systems and having diminished autonomy. Meanwhile, external rewards include compensation and recognition from patients.

It is critical to understand and balance how these components interact, according to the report. Moreover, addressing burnout requires collecting data on multiple measures, the report says. Press Ganey has developed an eight-point assessment tool to measure clinician resilience, which includes questions gauging capacity to disengage from work and ability to engage with work. Finally, staff needs to design interventions by communicating the seriousness of burnout, measuring engagement and resilience of physicians and other key personnel, promoting inherent rewards to boost clinician engagement and fostering a culture of wellness and resilience, the report says.

From the article of the same title
HealthLeaders Media (05/30/18) Cheney, Christopher
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Skyping the Doctor? More Older Patients Are Embracing Telemedicine
Most older Americans and their caregivers are willing to try telemedicine, such as a video visit via Skype or FaceTime to discuss medications. Nearly nine in 10 adults ages 40 and over would be comfortable using at least one type of virtual healthcare for themselves or an aging loved one, according to a new survey from The Associated Press-NORC Center for Public Affairs Research. Telemedicine also offers convenience to older adults who have chronic illnesses or mobility problems that make it difficult to even reach a doctor's office.

There are concerns, however. About one-third of respondents worry about privacy or the security of health information, and half fear that telemedicine could lead to lower-quality care, the poll shows. Insurance coverage is also an obstacle, as Medicare tightly restricts what it will pay for. Congress recently passed a law expanding Medicare coverage for such options as video visits to diagnose stroke symptoms or to check on home dialysis patients. In addition, Medicare Advantage programs used by one-third of beneficiaries can start offering other telehealth options.

"While the interest is huge, one barrier is reimbursement," said Johns Hopkins University telemedicine chief Dr. Ingrid Zimmer-Galler, who has turned to grants to help fund such services as telepsychiatry for dementia patients. The new law "is really a huge step in the right direction."

From the article of the same title
Associated Press (05/31/18)
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Health Policy and Reimbursement

Another Side Effect of Higher Minimum Wages: Lower Healthcare Benefits
A new working paper from the National Bureau of Economic Research found that employers forced to raise minimum hourly wages also raised the hourly wages of higher-paid workers to maintain parity. In addition, "robust evidence" shows that these employers also lowered the amount paid for employees' healthcare benefits to cover the additional costs. The research, which studied employee pay data from 2011 to 2016, found that among employees whose minimum wage rose by $1, 9 percent to 57 percent of their wage gains were offset by a decrease in their employer's health insurance coverage. Furthermore, many of these workers went without insurance instead of turning to the subsidies offered on the Affordable Care Act exchanges.

From the article of the same title
Washington Post (05/30/18) Marks, Gene
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New Push to Topple Affordable Care Act Looms
A group of Republicans and advocacy groups will soon release a proposal intended to spark another effort to repeal the Affordable Care Act (ACA). The proposal to topple the health law and replace it with a plan that would give states more control over health policy is the result of eight months of behind-the-scenes work by a coalition of conservative groups. A group of think tanks—including policy experts from the Heritage Foundation, American Enterprise Institute, Galen Institute and Manhattan Institute—plan to release a proposal in June. Representatives of the organizations, who have formed a coalition called the Health Policy Consensus Group, have been meeting weekly, working with state officials and reaching out to groups, including the U.S. Chamber of Commerce.

The plan reportedly has support from the White House. The proposal would end the ACA's expansion of Medicaid and would send money to states in the form of block grants. It would likely include some current ACA consumer protections, such as financial assistance to some people who cannot afford coverage, as well as an expansion of health savings accounts. To repeal the ACA with a simple majority—rather than the 60 votes usually needed for major legislation—Republicans would need to use a budget-related parliamentary procedure known as reconciliation, a move that could face resistance.

From the article of the same title
Wall Street Journal (05/26/18) Armour, Stephanie; Hughes, Siobhan
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Senate Bill Calls for Medicare Part D Electronic Prior Authorization
Lawmakers have introduced a bill that would enhance the use of electronic prior authorization (ePA) in Medicare Part D. Currently, prior authorization—a process that requests additional information about a patient to determine if an insurance plan will cover a drug—is completed through paper forms, faxes and telephone calls. However, the Electronic Prior Authorization in Medicare Part D Act proposes the use of ePA through a common electronic system. This would ensure that patients have speedier access to alternatives to opioid medications for chronic and acute pain and better access to medication-assisted treatment to treat opiate addiction.

Health IT Now's (HITN) Opioid Safety Alliance, a working group of stakeholders championing the use of technology to combat the illegitimate use of opioids, applauded the proposed legislation. "The nationwide opioid epidemic is a public health emergency that demands policymakers use every last tool at their disposal to prevent and treat cases of addiction, including technologies, such as ePA," said Joel White, executive director of the HITN Opioid Safety Alliance. "Private insurers, doctors and pharmacies are already using ePA to great success—decreasing provider burden and limiting the potential for medication mismanagement, including in cases of powerful opioids. It is past time we bring that same technology into the Medicare space."

From the article of the same title
Health Data Management (05/29/18) Slabodkin, Greg
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Medicine, Drugs and Devices

Pioneering Surgery Makes a Prosthetic Foot Feel Like the Real Thing
Researchers say they have created a brain-controlled robotic foot that has become a seamless part of the patient's body in a way that has never been achieved before with a prosthetic limb, according to a study published in Science Translational Medicine. After testing its capabilities through a series of experiments, the team made their most provocative observation: while sitting down, a patient fidgeted, pivoting the motorized ankle unconsciously. "A standard amputee, when they're wearing their leg, doesn't do any of that," said Dr. Matthew Carty, a Brigham and Women's Hospital surgeon and coauthor of the paper. "But [the patient], when he was sitting there talking to us, was fidgeting his bionic foot like it was his biological foot."

The key to success was combining a surgical advance with a technological one, according to the researchers at Brigham and the Massachusetts Institute of Technology. The researchers pioneered an entirely new kind of amputation and also developed a prosthetic foot that would enable two-way communication, with signals traveling from the patient's brain to the residual lower leg and into the robotic limb, and then back again. In the traditional amputation procedure, these connections are severed, but the new amputation recreates them. Most importantly, the research demonstrates the potential of the new system to restore a patient's sense of proprioception—a longtime challenge for developers of robotic limbs.

From the article of the same title
STAT (05/30/2018) Gil, Gideon; Orr, Matthew
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Realizing Blockchain's Security Potential Takes Work, Drug Companies Find
In 2017, five pharmaceutical companies formed the nonprofit group MediLedger to test blockchain for use in healthcare. The group wanted to find a better way to track drugs and guard against counterfeiters, but initial tests show that to make blockchain work in the supply chain, generic implementations are not enough.

MediLedger is adding mechanisms, such as expanded encryption techniques, to protect sensitive data. The pharmaceutical industry must meet new federal regulations in the United States beginning in 2019 that call for an electronic system to track certain prescription drugs in the country. Blockchain, the distributed ledger technology best known as the recordkeeping system behind cryptocurrencies, could be a neutral ground to share data to comply with the regulations, says Rashmi Kumar, senior vice president of data and analytics at distributor and MediLedger member McKesson Corp.

Still, some warn that before companies give over large pieces of their business to a blockchain, they must tailor security features to their needs. The MediLedger partners are not relying on a given blockchain platform's encryption methods alone. They are adding more levels of abstraction to their blockchain using technology called zero-knowledge proofs. For drug companies, zero-knowledge proofs allow the sharing of data about their data, without showing sensitive specifics, such as pricing and units sold, said Matt Langford, use case lead in data and analytics at McKesson.

From the article of the same title
Wall Street Journal (05/25/18) Nash, Kim S.
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The Heated Quest for Opioid Alternatives
Drug manufacturers are exploring a growing number of potential alternatives to opioid analgesics and are conducting clinical trials of several drugs designed to have little or no risk of abuse or addiction. "Pain drugs will get better," says Neil Singla, chief scientific officer at Lotus Clinical Research LLC, a company that conducts clinical trials and specializes in pain studies. "We've got enough darts out there that someone’s going to hit the bullseye."

Drugmakers are targeting new molecules and avoiding opioid receptors. One new target is nerve growth factor (NGF). In fetuses and infants, this protein, as its name suggests, promotes nerve growth. But when the nervous system matures, NGF's role is to process pain signals, says Ken Verburg, who heads Pfizer's effort with partner Eli Lilly to develop a drug that binds to nerve growth factor to prevent it from activating pain-signaling neurons. That medicine, tanezumab, has shown promise in several conditions.

However, U.S. regulators early this decade placed a partial hold on NGF trials after some patients developed a fast-moving form of the degenerative joint condition osteoarthritis. Pfizer and Lilly resumed Phase 3 trials in 2015 with a strategy to minimize risks for this problem. It includes lowering the top dose in chronic low-back pain and osteoarthritis patients and not studying tanezumab with NSAIDs. Phase 3 studies are continuing in osteoarthritis, chronic low-back pain and cancer pain, and results in osteoarthritis are expected in the second-half of this year, Verburg says.

From the article of the same title
Wall Street Journal (05/29/18) Gormley, Brian
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This Week @ ACFAS
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Mark A. Birmingham, DPM, FACFAS

Gregory P. Still, DPM, FACFAS

Jakob C. Thorud, DPM, MS, FACFAS

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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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