News From ACFAS

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ACFAS supports continuing education post-residency in the form of fellowships. Their fellowship initiative has provided status to 30 fellowship programs that have shown their ability to meet, and in most cases, exceed, a list of minimal criteria that assures their ability to provide adequate post-graduate education to their fellows. A listing of these programs, with websites dedicated to each, can be found at acfas.org.

The ACFAS Fellowship Committee’s annual application for new Recognized Fellowship Programs is due on August 31. If you are directing a fellowship, or are making inroads to start a new fellowship, and would like it to be considered for Recognition by the College, please contact Michelle Kennedy, Director of Membership to request an application and the list of Minimal Criteria for Recognition by ACFAS. Once all applications are received, the Fellowship Committee will be holding interviews with all programs in September.

For more information, please visit "Recognized Fellowship Initiative" on acfas.org. Take advantage of some summer down time to catch up on your research reading with ACFAS' Scientific Literature Reviews (SLRs). SLRs are bite-size reviews of the latest foot and ankle research available in journals you may not regularly read.

SLRs are published on acfas.org monthly and are prepared by residents from programs around the nation. The latest reviews are available and include such articles as:

• Biomechanical Assessment of Flexible Flatfoot Correction
• Comparison of Clinical Outcome of Pronation External Rotation Versus Supination External Rotation Ankle Fractures
• Ankle Radiographs in the Early Postoperative Period: Do They Matter?
• Risk Factors for Methicillin-Resistant Staphylococcus Aureus in Diabetic Foot Infections

Foot and Ankle Surgery

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The findings of a recent study suggest that femoral reamer-irrigator-aspirator (RIA) bone graft is a viable alternative to iliac crest bone graft (ICBG) for tibiotalar fusions. The study involved a retrospective review of charts and radiographs at final follow-up for patients who had undergone tibiotalar fusion using one of the two techniques. The study found that patients who were treated with ICBG had significantly more non-unions than did patients treated with RIA. In addition, a review of the current visual analog scores (VAS) at patients' graft sites indicated that two individuals treated with ICBG experienced chronic pain at this location. The VAS scores of patients in the RIA group indicated that none of these individuals experienced such pain. No significant differences were seen between the two groups in terms of radiographic fusion.

Practice Management

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Doctors' practices that are not ready for the transition to ICD-10 should take advantage of the decision to delay the adoption of the new coding system by beginning or continuing their preparations. One area that practices should focus on is continuing to practice applying the documentation principles of ICD-10 to clinical documentation improvement. These principles can be applied to the current ICD-9 coding system to ensure that quality, severity, and risk are appropriately documented. In addition, practicing the application of ICD-10's documentation principles is important because the principles are key elements in the incentive initiatives offered by the federal government and third-party payers when they are reported along with diagnoses that support quality, severity, and risk. Another step that doctors' practices should take to prepare for the implementation of ICD-10 is to ask electronic health record (EHR) and practice management vendors who have identified bugs in ICD-10 systems to correct these flaws before ICD-10 goes live. Providers and practice staff members should also be sure to review the codes that support medical necessity in the local coverage determinations (LCDs) that were issued by Medicare Administrative Contractors (MACs). Doing so will make it easier for practices to identify the additional characters that are needed for the codes and categories listed in the LCDs.


Healthcare interpreters who speak both English and another language are increasingly in demand by healthcare providers as the patient population becomes more diverse. Healthcare interpreters play an important role in providing care to non-English-speaking patients, since they are able to communicate with patients in their native language and because they are capable of accurately translating a doctor's statements. For example, healthcare interpreters can help doctors ensure that their patients understand their diagnoses and any recommended treatments. And because healthcare interpreters are taught not to become emotionally or personally invested in a patient, they can translate a doctor's remarks without leaving out important information the way a patient's family member may do. This in turn ensures that patients receive the care they need, while also reducing the chances that the healthcare provider will be held liable if something goes wrong. Healthcare interpreters are also subject to a set of national standards, and some are required by their employers to be certified and undergo training. Healthcare providers who receive federal funds are required by law to provide free interpreting services from in-house interpreters, freelance interpreters, and/or interpreters who are present via phone or video conferencing.


Healthcare industry observers say drug diversion, in which healthcare workers steal and use injectable drugs and then sometimes use those same syringes on patients, is a bigger problem than commonly thought and one that affects physicians' practices, hospitals, and any other organization that handles controlled substances. A paper published June 2 in the journal Mayo Clinic Proceedings found that "tampering" of patients' medications by healthcare workers resulted in 118 patients being infected over the last 10 years. However, one of the paper's authors said that figure likely understates the scope of the drug diversion problem, given the fact that 100,000 employed healthcare workers are known to have substance abuse problems. The best thing that healthcare organizations can do to address the problem of drug diversion is to quickly identify healthcare workers who may be stealing drugs and respond in an appropriate manner, says drug diversion consultant Kim New. However, healthcare organizations tend to not be vigilant about the possibility that employees may be engaging in drug diversion, says one of the authors of the recent paper, and if they do identify cases of drug diversion they generally fail to report them to authorities for a variety of reasons. An editorial that was published along side the recent paper in Mayo Clinic Proceedings also noted that healthcare organizations may balk at the cost of drug diversion and detection programs, though it goes on to say that such programs are absolutely necessary despite their cost given the negative impact drug diversion has on patients.

Health Policy and Reimbursement

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A new study by the McKinsey Center for U.S. Health System Reform suggests that consumer demand for lower-cost narrow-network health insurance plans is driving demand for these policies on health insurance exchanges and in the individual market. The study found that roughly half of the policies sold on the exchanges this year were narrow-network plans, which were defined as those that cover 30 to 70 percent of hospitals in a particular area. That percentage increased to 60 percent in the largest city in each state, the study found. The study also noted that narrow-network plans were more widely available than broad-network policies, or those that covered 70 percent or more of hospitals in an area. Narrow-network plans were available to 92 percent of consumers shopping for health insurance coverage on the exchanges, the study found, while 90 percent of these consumers had the option of selecting broad-network plans. On the individual market, meanwhile, companies that are selling individual policies are also offering a large number of narrow-network plans. Only 10 percent of the policies on the individual market that were offered by insurance companies that previously only covered Medicaid beneficiaries were broad-network plans, though non-profit co-ops were offering an equal number of narrow-network and broad-network plans on the individual market, the study found.


David Brat's upset victory over House Majority Leader Eric Cantor in the Republican primary election on June 10 could have a number of ramifications for any healthcare legislation that is taken up by the lower chamber. For example, the outcome of the political jockeying for Cantor's post may affect the leadership of the Ways and Means and Energy and Commerce committees, as well as other House panels with jurisdiction over healthcare issues. In addition, Cantor's defeat by a candidate who has vowed to repeal the Affordable Care Act (ACA) underscores the fact that the Republican base remains adamantly opposed to the law. This in turn could make it difficult for House Republicans to convince members of their caucus to retain ACA but make minor changes. Cantor's loss means that there is one less House Republican who supports passing an alternative to the Affordable Care Act. However, several other House Republicans support a proposal that would expand the use of health savings accounts, allow consumers in one state to purchase health plans in another, and reform medical malpractice laws. One Republican who supports this proposal, Rep. Steve Scalise of Louisiana, could wield influence over how the House moves forward with this and other proposals should he win his bid to be the next House whip. Democrats in the Senate, however, remain largely opposed to any effort to replace ACA.


The Centers for Medicare and Medicaid Services (CMS) has released the results of the ICD-10 claims acknowledgement tests that were conducted in early March. All of the 2,600 participants received electronic acknowledgements for the roughly 127,000 ICD-10 claims that were submitted to Medicare Fee-for-service (FFS) claims systems, while 89 percent of those claims were accepted. However, acceptance rates were as high as 99 percent in some parts of the country, CMS said. Some of the claims that were submitted by participants--which included both large and small doctors' practices as well as ambulatory surgical centers--deliberately included errors that would result in the claims being rejected. CMS said in a report detailing the results of the testing that providers, suppliers, billing companies, and clearinghouses can submit acknowledgement test claims up until ICD-10 goes live on Oct. 15, 2015, though it recommended that they may want to hold off on acknowledgement testing until after Medicare updates its systems on Oct. 6.


The U.S. Senate is considering legislation that will increase the number of Medicare-supported residency positions at the nation's hospitals by 15,000 over the next several years. Hospitals that serve rural areas where there are not enough doctors would be given preference when assigning the additional residency positions, as would hospitals that train physicians in community health centers or outpatient departments. In addition, half of the new residency slots would be set aside for primary care physicians. Sen. Charles Schumer (D-N.Y.), one of the sponsors of the Resident Physician Shortage Act, plans to attach the measure to his planned effort to eliminate the Medicare Sustainable Growth Rate (SGR) formula and adopt permanent Medicare rates. The bill is intended to address the shortage of doctors at hospitals in some parts of the country--a shortage that some hospitals believe is putting patients at risk.

Medicine, Drugs and Devices

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A Phase II trial has found that brodalumab is effective in treating psoriatic arthritis. During the trial, patients were randomized to receive a placebo or the 140 mg or 280 mg doses of subcutaneous brodalumab at day one and again during six subsequent weeks. Both doses of brodalumab were superior to placebo in bringing about a 20 percent improvement in the American College of Rheumatology response criteria (ACR20) at week 12. These responses, which included joints that were less tender and swollen as well as improvements in other signs and clinical symptoms of psoriatic arthritis, continued to improve through week 24 and were sustained through week 52. Brodalumab has now moved into two Phase III trials that are examining the effects the treatment has on improving clinical signs and symptoms of psoriatic arthritis and its effectiveness in preventing joint damage.


Patients suffering from distal lateral subungual onychomycosis (DLSO) now have a new treatment available to them, thanks to the Food and Drug Administration's recent decision to approve Valeant Pharmaceuticals' new drug application for the topical triazole treatment Jublia. The decision means that Jublia is the only topical triazole agent on the market that is intended for treating DLSO, a common and destructive form of infection that affects toenails. DLSO is currently undertreated because existing treatments--including the use of topical medications, often in conjunction with frequent debridement--are limited in their effectiveness. Jublia is expected to be introduced in the U.S. sometime in the third quarter.


The use of recombinant human bone morphogenetic protein-2 (rhBMP) as an augment for bone healing for patients undergoing certain types of foot and ankle surgeries is both safe and effective, a new study has found. The study involved a retrospective review of 51 cases in 48 patients who underwent foot and ankle fusions or fracture non-union revisions and were thought to be at high risk of non-union following surgery. RhBMP-2 was used as an augment for bone healing in all of these patients. Union was achieved in 92.2 percent of cases, while the union rate for the 82 individual sites treated with rhBMP-2 was 95.1 percent. Average time to union was 111 days. A low rate of complications was observed in patients treated with rhBMP-2. However, the study noted that more randomized control trials that examine the use of rhBMP-2 are needed.