News From ACFAS

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Tune into Charcot: Back to the Drawing Board, this month’s free clinical session, and find new solutions for treating this complex foot condition.

Case-based presentations in the June session include:

• Biomarkers: What Have We Learned from the Test Tube?
• Bone Healing with Internal or External Fixation: Does It Matter and What Are We Measuring?
• Conservative Treatment: Is It More Successful Than You Think?
• Medical Management: Which Pharmaceuticals Are Making a Difference?
• Surgical Reconstruction: When Is It Truly Necessary?
• Can Amputation Be Possibly Better Than Salvage?

Access this session now at acfas.org/e-learning and be sure to complete the CME test after you watch the presentations so you can earn continuing education credit. Remember, the ACFAS e-Learning Portal also has monthly podcasts, downloadable Surgical Techniques videos, e-Books and other resources for convenient remote learning that is always ready when you are. Use FootHealthFacts.org, the College's consumer website, to attract new patients and referrals to your practice and to also enhance your practice website. You can:

• Include a link to FootHealthFacts.org on your practice website's homepage and direct patients there for valuable foot and ankle health information
• Link to specific articles, condition pages and videos featured on FootHealthFacts.org
• Encourage patients to use the Where Do You Hurt? interactive foot diagram
• Remind patients to follow FootHealthFacts.org on Twitter and Facebook

FootHealthFacts.org is free to use and continually updated with new content. If you have any questions about how to make FootHealthFacts.org work for you, contact Jolinda Cappello, ACFAS communications manager, at (773) 444-1320. ACFAS wants to know if you believe the The Journal of Foot & Ankle Surgery includes the right balance between the number of original research articles and the number of case reports. Vote in this month’s poll at right to let us know, then visit acfas.org throughout June for real-time results. Thank you for sharing your feedback!

Foot and Ankle Surgery

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A study was conducted to explore different approaches of accounting for bone mineral densities (BMD) in the development of human injury risk curves. The researchers used simulated underbody blast (UBB) loading experiments conducted with the postmortem human subject (PMHS) lower leg-foot-ankle complexes to compare between treating BMD as a covariate and prescaling test data based on BMD. Twelve PMHS lower leg-foot-ankle specimens underwent UBB loads, and calcaneus BMD was acquired from quantitative computed tomography (QCT) images while fracture forces were recorded via a load cell. The average peak forces of 3.9 kN and 8.6kN correlated with the five percent and 50 percent likelihood of injury for the covariate method of deriving the risk curve for the reference age of 45 years. The average forces of 5.4 kN and 9.2 kN were associated with the five percent and 50 percent likelihood of injury for the prescaled method. The normalized confidence interval magnitudes were higher in the covariate-based risk curves compared to the risk curves based on the prescaled method. The latter technique supported an overall greater injury force and a tighter injury risk curve confidence interval. When compared with the use of spine BMD from QCT scans to prescale the force, the calcaneus BMD scaled data generated more force at the same risk level overall.


New research seeks to determine local and systemic markers of inflammation and bone mineral density (BMD) in the foot and central sites in participants with diabetes mellitus and peripheral neuropathy (DMPN) with and without acute Charcot neuropathic osteoarthropathy (CN). Eighteen participants with DMPN and CN and 19 participants without CN had foot temperature assessments, serum markers of inflammation [C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR)] and BMD of the foot, hip and lumbar spine at baseline and one-year follow-up. CN foot temperature difference was higher compared to DMPN controls at baseline and after one year. Serum inflammatory markers in the CN group were greater at baseline and remained elevated one year later compared to DMPN controls. All pedal bones' BMD decreased by an average of three percent in the CN foot with no changes in hip or lumbar spine. DMPN controls' foot, hip and lumbar spine BMD remained unchanged. Local and systemic inflammation persisted one year after CN with an accompanying pedal osteolysis that may contribute to midfoot deformity, which is the hallmark of the chronic Charcot foot, researchers concluded.


New research presents an operative technique of arthrodesis for the reconstruction of the ankle and hindfoot with a large bone defect using a soft tissue–preserved fibular strut graft. Researchers treated the feet of 11 patients, including feet with aseptic necrosis of the talus and total ankle implant loosening. Bone defects were filled using iliac bone and/or resected fibula, and tibiotalocalcaneal arthrodesis was performed using a retrograde intramedullary nail. A modified transfibular approach was used to expose the affected joint while preserving the lateral to posterior skin and soft tissues on the fibula. Bony fusion was achieved within three months in all cases. Coronal and sagittal alignments were acceptable, and the mean American Orthopaedic Foot & Ankle Score improved from 53.8 to 75.5 at the final follow-up. All patients graded their results of treatment as “satisfied.” The procedure did not require special techniques, and it should apply to complicated cases with large bone defects. High fusion rates—likely due to preserving blood supply to the fibular graft—can be expected with preservation of the hindfoot height, researchers concluded.

Practice Management

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Information technology (IT) often controls several systems that manage the daily operations of a medical practice. As a result, it is imperative that owners set up emergency IT access protocols in the event an IT employee is unavailable. These plans can ensure business continuity and are required to be updated regularly by the HIPAA Security Rule. These plans should include access to administration accounts, hardware and network equipment, applications, service provider credentials, website and domain information and software licensing information.


According to an American Medical Association study, only 47.1 percent of physicians had ownership stakes in a medical practice last year. That is a decline from 53.2 percent in 2012. Researchers say that decline can be attributed to more doctors, young ones in particular, opting to join larger practices. Other factors include rising compliance costs and new payment models associated with owning a practice. Information technology and safety concerns must be addressed as well. The research also found that the number of physicians working in hospital-owned practices has gone relatively unchanged between 2014 and 2016.


The Health Insurance Portability and Accountability Act (HIPAA) mandates the appointment of a security officer, and Sandberg Phoenix & von Gontard's Diane Robben advises practices to seriously consider the talents and skills of each staffer, which could make the difference between having a security officer in name only and one who is committed to his or her responsibilities. Robben suggests having separate people fill the positions of privacy officer and security officer allows for checks and balances. She stresses the security officer must concentrate more on the technology side of operations and should know:

• whether or not physicians and staffers are accessing protected health information (PHI) from their phones or tablets
• whether there is even a slim possibility of a laptop containing accessible PHI being lost or stolen
• where physical charts are within the office

Robben notes a lack of technological knowledge is not a great hardship for a security officer in small practices. “The security officer need not have all the answers, but s/he needs to be able to [identify] the issues,” and know when to ask for help, she emphasizes. Robben recommends that practices seek an individual who will look for educational and learning opportunities and who will read the latest HIPAA and technology news. “You want someone who will be proactively looking at the systems and the organization and who will take steps to tighten things down instead of waiting to react when something happens, because something will happen,” she says.

Health Policy and Reimbursement

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A group of 184 lawmakers wants the U.S. Department of Health and Human Services (HHS) to reverse an Obama-era policy that discourages insurers from accepting payments from hospitals or other entities to obtain insurance on the exchange for their patients. A 2013 memo suggested that insurers reject payments from hospitals, healthcare providers or commercial entities because those payments were given to people who could skew the risk pool on the exchanges. On May 31, the lawmakers wrote a bipartisan letter to HHS Secretary Tom Price saying the policy has resulted in insurers dropping their sickest and low-income enrollees. "This practice essentially allows insurers to steer patients to the government or to other plans to avoid providing coverage." The lawmakers' letter also urged HHS to swiftly issue a new policy that would allow not-for-profit charitable organizations, places of worship and local civic organizations to make premium payments on behalf of enrollees. Hospitals have been pushing back against the policy for years. In 2016, the American Hospital Association sent a letter to the U.S. Centers for Medicare & Medicaid Services, asking that the policy be reconsidered. "Access to coverage and routine health care should take precedent over any concerns about the risk pool," the trade group said in the letter.


Medicare officials have announced the agency's plan to replace Social Security numbers on Medicare cards with randomly generated digits and letters—known as Medicare Beneficiary Identifiers (MBIs)—to protect the elderly against identity theft by April 2019. Beneficiaries and their families should begin to see such changes by April 2018, when Medicare will start mailing out new cards to more than 57 million senior and disabled beneficiaries. Medicare Director Seema Verma says the Trump administration is targeting "a seamless transition" over a period of 21 months, involving coordination with beneficiaries, their relatives, hospitals, physicians, insurance firms, pharmacies and state governments. The MBIs are expected to have 11 characters containing random numbers and upper-case letters to easily distinguish them from Social Security numbers.


President Trump is urging revisions to Senate rules to allow all bills to pass with a simple majority, pushing aside the GOP's current legislative strategy on healthcare and taxes that already rests on securing such a majority. Tweets by the president have instigated new questions about how Trump views both issues. Trump tweeted about the healthcare bill that has already cleared the House, which his own aides hope will not be killed by the Senate in a bid to start over. “I suggest that we add more dollars to Healthcare and make it the best anywhere. ObamaCare is dead—the Republicans will do much better!” Trump tweeted. The Republican healthcare plan is founded on a repeal of the Affordable Care Act (ACA) and much of its associated funding, as well as new provisions offering financial aid and incentives for people to acquire health coverage. The Congressional Budget Office says tossing the ACA and enacting the GOP replacement would result in less federal spending, not more. Democrats have been unanimous in opposing such actions.

Medicine, Drugs and Devices

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A study presented at the European Congress of Endocrinology 2017 found sequential osteoporosis treatment using denosumab one year after halting use of teriparatide leads to a higher additional bone-mineral density (BMD) increase versus use of a bisphosphonate, with a more noticeable effect at the lumbar spine. The retrospective analysis was comprised of data from 140 women, average age 74, exhibiting severe postmenopausal osteoporosis who had been treated with teriparatide for 18 to 24 months between 2006 and 2014. The average BMD increase at the lumbar spine in patients on denosumab was about 0.04g/cm2, compared with no boost in patients taking bisphosphonates. Overall, 5.7 percent of patients on denosumab suffered fractures of the rib and other nonvertebral bones versus 17.1 percent of patients on bisphosphates. The outcomes indicated a reduced BMD increase in patients on bisphosphonates when compared with denosumab and a lower BMD increase at the femoral neck and lumbar spine.


A study published in JAMA Internal Medicine found drug rebates may in fact elevate the sum Medicare and its beneficiaries pay for drugs, particularly for increasingly common high-priced drugs. "How these rebates and price concessions happen between the manufacturer of the drug and the PBMs [pharmacy benefit managers] and health plans can directly affect patient cost in a big way," notes lead author Stacie Dusetzina with the University of North Carolina-Chapel Hill's pharmacy school. Rebate savings are not necessarily passed on to patients in Medicare's system, but rather they are taken up by health insurers and intermediaries, such as PBMs. In addition, Dusetzina says although patients do not pay list prices for their drugs, those high prices are applied to the estimation of how much Medicare covers for any individual patient and sometimes what patients pay out-of-pocket. Dusetzina and the study's coauthors recommend that patients be charged flat-dollar copays instead of coinsurance charges, which are based on a percentage of the drug's price. They suggest that the copays could be tiered, according to the cost of the drug. Another possible solution is to address the intrinsic disconnect between rebate negotiations and savings for Medicare and beneficiaries, with the authors suggesting that incentives for health insurers should change to stipulate that health plans pay more of the drugs' costs after beneficiaries pass through the "doughnut hole," where they pay a larger share of the drug's price after their spending reaches $3,700.


Researchers at the University of Pennsylvania Health System have developed a machine learning tool that can help predict patients at highest risk for developing severe sepsis. The team validated the algorithm in clinical practice using a sample of more than 10,000 individuals. The researchers report the tool was able to identify patients headed for severe sepsis or shock a full 12 hours before the onset of the illness. “We were hoping to identify severe sepsis or septic shock when it was early enough to intervene and before any deterioration started,” says senior author Craig Umscheid, MD, of the Hospital of the University of Pennsylvania. “The algorithm was able to do this." The machine learning tool can monitor hundreds of key variables in real-time. The team used electronic health record data from more than 160,000 patients and a random forest classifier to train the algorithm. Umscheid and lead author Heather Giannini, MD, presented their study on the machine learning tool at the 2017 American Thoracic Society International Conference.