News From ACFAS

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Show us where your feet take you! Be part of ACFAS’ new #KeepYouOnYourFeet social media awareness campaign to show how foot and ankle surgeons help keep the world “on their feet” to do the things they love.

Share photos of your feet hard at work, on vacation, exploring the world or just living day-to-day life, and use #KeepYouOnYourFeet in your posts so we can be with you on your journey. Also encourage your patients to post photos of their feet on the move using the #KeepYouOnYourFeet hashtag.

Want us to post your photo to ACFAS’ social media pages? Send your photos to melissa.matusek@acfas.org and be sure to add your name, the location or action in the photo and where you practice. When a stressful or unexpected situation arises in your practice, don’t let it throw you off your game. ACFAS’ latest free Clinical Session, “Game Changer: Lessons from Harrowing Experiences (YMR),” identify strategies to help you:

• Recognize the signs of burnout and its contributing factors
• Achieve work/life balance
• Apply “how tos” in your practice

This Clinical Session includes four presentations that address some of the most common stressful situations a foot and ankle surgeon might face:

• The Second Victim: Effect of Medical Errors on Providers
• Managing Ones Emotions After Being Sued
• Achieving Balance
• Anatomy of a Malpractice Case

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 1.5 continuing education contact hours. Visit the ACFAS e-Learning Portal often for monthly podcasts, Surgical Techniques videos, e-Books and other resources for convenient remote learning that always fits your schedule. Listen to this month’s podcast, “Arthrodesis vs. Arthroplasty of the Ankle,” for honest, straightforward views on the benefits and limitations of each procedure. Hear your colleagues explain how to evaluate patients for arthrodesis or arthroplasty while taking into account patients’ activity level and lifestyle. Also learn strategies for reducing complications that could stand in the way of achieving the best possible outcomes for your patients.

Visit acfas.org/e-learning for ACFAS’ complete podcast library to start planning your summer playlist. New releases are added monthly so you can always stay one step ahead of trending topics in the profession. ACFAS’ monthly Scientific Literature Reviews (SLRs) make the perfect traveling companion for long summer road trips and flights. Read these quick, concise summaries of studies from leading medical journals to stay up to date on the latest advancements in foot and ankle surgery that may affect your own cases.

This month’s SLRs cover diabetic foot ulcers, idiopathic toewalking, tendon-to-tendon repair and more, and each includes podiatric relevance, methods, results and conclusions. Head to acfas.org/SLR to read the June SLRs or to browse the SLR archive for studies dating back to 2009.

Foot and Ankle Surgery

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Anatomic repair of the anterior talofibular ligament (ATFL) is difficult when the local ligamentous tissue is severely attenuated. Anatomic reconstruction of the ATFL with tibial tuberosity-patellar tendon (TT-PT) autograft is a feasible choice that can avoid the complicated tendon-bone healing and restore ankle stability.

From 2009 to 2015, 31 patients with chronic lateral ankle instability (CLAI) who only had a serious injury on the ATFL were treated with anatomic reconstruction of ATFL with TT-PT. Radiographically, talar tilt angles and anterior drawer were assessed in pre- and postoperative ankle stress views. Among the 31 ankles, 17 ankles with single-bundle ATFL and 14 ankles with double-bundle ATFL were found at operation. At a mean follow-up of 42 months, all patients were satisfied with the procedure. Mean AHS significantly increased from 60.5 to 93.5, while mean Karlsson-Peterson score declined from 55.2 preoperatively to 91.2 at final follow-up. Average VAS fell from 5.9 preoperatively to 1.4 at the latest follow-up. Mean Tegner activity level was 3.7 before operation, compared with 7.0 after operation. On stress radiographs, mean talar tilt angle was 17.0 before operation and 3.8 at the latest follow-up, while mean anterior tibiotalar translation was 7.5 mm before operation and 1.8 mm at the latest follow-up.

The researchers concluded that anatomic reconstruction of the ATFL using a TT-PT autograft allows bone-bone healing in talus and tendon-tendon/periosteum healing in fibula rather than requiring tendon-bone healing, which is an alternative option for treating CLAI caused by single ATFL insufficiency.


A study was conducted to test the use of electromagnetic simulation with boundary conditions set at various layers of human tissues, analyzing the human foot via COMSOL multiphysics software to visualize, analyze and measure the degree of peripheral vascular disease as it progresses in diabetic foot ulcers (DFU). The model was conducted for a patient's foot, with bone, blood vessels and surrounding fat layers to mimic the anatomy of a diabetic foot.

A two-dimensional (2D) scan was acquired to evaluate and visualize the blood vessel's occlusion. The analysis was performed at the 2-GHz and 5-GHz frequencies and compared to one another to assess the precision of clinical diagnosis. An electric field was produced throughout the 2D model at 20, 50 and 100 Joules, respectively. The model adequately predicted and stratified varying degrees of occlusion within peripheral vasculature.

This feasibility study has potential to accurately diagnose the peripheral vasculature using electromagnetic parameters, and it has proven successful for possible future deployment using MEMS/NEMS device systems to be designed to detect EM parameters to function as a diagnostic tool for the early detection of peripheral vascular disease and DFU.


A study was conducted to assess introduction of the intraoperative radiological indicator to evaluate reduction adequacy without additional procedure or instrument and to propose the optimal syndesmotic screw trajectory. For the study, 30 adult cadavers lacking ankle problems underwent continuous 0.75 mm-slice computed tomography (CT) scans. The images were imported into software to reconstruct three-dimensional (3D) ankle models using free 360-degree rotations with magnification to rate the three-dimensional (3D) mutual relationships of ankle syndesmosis and the fibular congruency of incisura to ascertain optimal screw trajectory.

Reformatting the CT scanning plane along the screw direction enabled evaluation of the coronal relation of ankle syndesmosis to confirm distance between the adjacent bones. The fibula was positioned in the concentric position of fibular incisura in the 20 models,and in an eccentric position in 40 models. All fibulas were changed into the concentric position in the proximal part of syndesmotic footprint, which might be the optimal height for syndesmotic screw.

The fibular bisecting screw trajectory tied to the ideal height of screw was parallel to the ground if the tibial tubercle was directed to the superior and nearly vertical to the ground floor. Via the reformatted scanning plane parallel to the screw, the lateral border of talus was always positioned more medial than the lateral border of distal tibia in the coronal image; all models had a perfectly equidistant and parallel joint space apart from the medial aspect.

Practice Management

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New Jersey health system RWJBarnabas Health has launched a handful of initiatives over the past year to curb workplace violence at its hospitals and clinics. One of its projects has been creating facility safety assessments that aim to ensure buildings are as safe as possible. This includes making sure they have the most updated technology and checking their visitor access system and security workforce, says Nancy Holecek, senior vice president and CNO of RWJBarnabas Health's Northern New Jersey Region.

RWJBarnabas has also instituted quick reporting technology for violent incidents, especially since minor incidents or threats largely go unreported. This allows staff members to click on a computer desktop icon and to quickly file reports on workplace violence. In addition, the health system has worked to raise awareness among staff about workplace violence, which boosts safety and increases the likelihood of reporting, Holecek says. It also enhanced its Behavioral Emergency Safety Training (BEST) with the help of a consultant.

"The focus is to deescalate the behavior—not to pin the person against a wall, not to smother the person. This has been very successful," said Holecek. The consultant is adding a new layer to the BEST training—instructing staff about duty to warn, duty to act and duty to respond. Finally, the health system has added violent incidents to daily debriefings at each of its 11 hospitals and formed a steering committee to lead workplace violence prevention efforts.


At the American Medical Association House of Delegates meeting, experts gathered to discuss the challenges of reporting sexual harassment in the medicine and healthcare industries. Panelists at the meeting noted that swift punishment and warnings should follow any instance of sexual harassment. However, they also said reporting sexual harassment can potentially hurt a career. For example, a survey of women who reported sexual harassment said their experiences "negatively affected their career advancement."

The experts recommended that facilities take proactive steps to deal with sexual harassment. Among the suggestions were anonymous reporting systems, live training sessions, mentors and professional help options for victims.


Medical practices typically invest in search engine optimization strategies for their websites but may be unaware that the website should be a virtual extension of the physical practice. Along with providing basic contact information—phone, fax, hours and location—the website should convey the personality and clinical philosophies of the office, as well as offer specific information about the physicians and services.

A first step is ensuring the practice's branding is consistent across all physical and virtual assets, including logo, colors and fonts. Furthermore, allowing patients to book appointments online can free up staff time and offer patients greater convenience. Practices should also make use of their electronic health record system vendor's patient portal.

Beyond utility, the website should tell the practice's story. For example, practices might describe the clinicians' interests and whether they have a focus on a particular area. The website can also link to or include patient testimonials about clinicians and feature short video vignettes. By asking patients for feedback at checkout, any unfavorable impressions can be dealt with immediately, while satisfied patients will be encouraged to write a review.

Health Policy and Reimbursement

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Minnesota is one of a growing number of states testing a Medicaid payment system that rewards hospitals and physician groups for controlling costs by keeping enrollees healthy. Under this arrangement, those healthcare providers are not only asked to treat medical issues, but also to address the underlying social issues—such as homelessness, lack of transportation and poor nutrition—that can cause and aggravate health problems.

The shift toward this new model of care, called accountable care organizations (ACOs), is occurring with Medicare and employer-sponsored insurance as well. But for Medicaid programs, it presents unique challenges. Medicaid enrollees are low-income, and many are homeless or dealing with mental health problems, which can lead to difficulties in encouraging healthy behaviors. While the switch to ACOs accelerated efforts by hospitals and physician groups to attack social determinants of health, providers still struggle to change patients' behaviors, particularly helping those with addiction and mental health problems, according to interviews with officials at several ACOs.

Minnesota's experience demonstrates the challenges of transitioning to a new Medicaid payment system. In 2016, only six of the 16 ACOs were eligible to share in cost savings. However, the state's program has seen a 7 percent decline in emergency room visits and a 14 percent drop in hospital stays in areas where health providers participate in an ACO, according to Marie Zimmerman, Minnesota's Medicaid director.


Practices may face "topped-out measures" as they conduct their quality reporting under the U.S. Centers for Medicare and Medicaid Services' (CMS) Merit-Based Incentive Payment System (MIPS) in 2018. "Topped-out measures" refer to quality measures in which "meaningful distinctions and improvement in performance can no longer be made," according to CMS. For instance, a process measure would be topped-out if median performance is 95 percent or higher—or 5 percent or lower if it is scored inversely, both of which would be deemed too easily attainable.

Topped-out measures may make it difficult for practices to receive the maximum number of points under the Quality Payment Program, but by identifying measures as topped-out, CMS is incentivizing practices to choose other measures where greater performance improvement is more likely. Some topped-out measures may remain in the program for longer than four years as CMS considers the maintenance of measures that contribute important aspects of patient safety and reliability.

Practices are advised to compare the current 2018 MIPS Quality Benchmarks, review their numbers at least quarterly, select the appropriate measures and engage an expert quality reporting team.


The GOP has abandoned its plans to revamp Medicare as new forecasts indicate Medicare's trust fund is in poor shape partly due to Republican tax cuts. A Medicare board of trustees' report says those cuts will add $1.5 trillion to the deficit, slowing the flow of Medicare funding and further destabilizing the program. Furthermore, the decision to eliminate the Independent Payment Advisory Board will put additional pressure on Medicare's finances, with its hospital trust fund currently projected to run out by 2026, three years earlier than predicted.

The GOP must also weigh President Trump's likely antipathy toward a proposed overhaul of Medicare. Some Republicans still believe a resurgent economy will alleviate financial pressure on the program's trust funds. The trustees' report anticipated that the GOP tax cuts would lower the income taxes people pay on Social Security benefits, part of which are channeled into Medicare. The tax law's repeal of the Affordable Care Act penalty for lacking insurance will drive up the uninsured rate, hiking Medicare payments for uncompensated care.

Medicare's Paul Spitalnic says lower-than-expected tax returns account for the "vast majority" of this year's funding shortage, and the trustees found payroll and income taxes cannot cover Medicare's budget gap, partly because of the tax law. Rep. Steve Womack (R-Ark.) argues that the report highlights the need for the House to unite behind a fiscal plan that includes entitlement reform.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration (FDA) has approved a wearable device to treat opioid withdrawal symptoms, such as anxiety, depression and opiate cravings. The Drug Relief device, developed by DyAnsys, sends electrical pulses through ear-fitted needles to provide continuous treatment for up to five days. The company said the "percutaneous electrical nerve field stimulator" is already available to providers to aid in opioid detoxification. "We are in a full-blown crisis and need nonnarcotic options and alternatives like this that can make a significant difference for individual patients and their families," said Srini Nageshwar, CEO of DyAnsys.


Medical costs are expected to grow by 6 percent in 2019, continuing their relatively flat growth of the past five years. Yet higher costs have not translated to similar gains in consumers' health and productivity, according to PricewaterhouseCoopers. Costly new medical services and drugs and market consolidation are driving higher costs, said Barbara Gniewek, a health services principal at PwC. "It looks like costs are stabilizing, but they are still going up at a rate above inflation," she said.

As health systems consolidate and acquire physician practices, prices tend to increase through facility fees and other fixed costs, according to the report. Providers, employers and health plans are offering consumers new healthcare access through telehealth, retail and urgent-care clinics. The goal is to reduce spending, but improved access often leads to higher utilization in the short-term, PwC researchers said.

To continue to lower costs, employers and health plans likely will have to address prices—and not just drug prices, according to the report. That will require employers and insurers to collaborate with numerous stakeholders, from pharmacy benefit managers to retail pharmacies. They will need to justify the price of services by demonstrating their value, get comfortable working with third parties advocating for patients and target investments that enhance the customer experience.


As many as 1,000 patients experienced adverse events from cybersecurity attacks on healthcare delivery organizations involving ransomware, malware or an attack on an electronic health record system, according to a new survey of executives of device manufacturers and provider organizations. The results of the survey, conducted anonymously by researchers at the University of California San Diego, were announced at the HIMSS Healthcare Security Forum.

One respondent from a medical device manufacturer said they were aware of an adverse event that occurred due to an existing security vulnerability in a medical device but did not reveal how many patients were involved. Of the 40 executives from some of the biggest medical device vendors and provider organizations, two from healthcare delivery organizations said 100 to 1,000 patients were harmed during an unreported adverse event related to a medical device cybersecurity vulnerability.

In addition, 20 percent of respondents did not implement new policies based on the U.S. Food and Drug Administration's pre- and postmarket cybersecurity guidance, which includes regulations for meeting mandatory quality system regulations. The same percentage said they do not intend to implement any new policies. Eighty percent of respondents said cybersecurity risks are worse than the media's perception.