News From ACFAS

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Have a hand in maintaining the quality and accuracy of the abstracts featured in each issue of This Week @ ACFAS by volunteering to be a This Week content reviewer.

Content reviewers receive a This Week preview every Friday and check the abstracts listed under each section (Foot and Ankle Surgery, Practice Management, Health Policy and Reimbursement, and Medicine, Drugs and Devices) for relevance and technical/medical accuracy. The reviewers then email their changes and input to ACFAS staff for implementation.

If you would like to serve as a This Week content reviewer, please contact Melissa Matusek, CAE, ACFAS director of Marketing and Communications, at (773) 444-1306. Put ACFAS’ e-Books, Arthroscopy of the Foot and Ankle and The Art and Science of Orthobiologics for the Foot and Ankle, at the top of your summer reading list.

Vivid full-color images and videos take you into the OR and guide you through the latest surgical procedures and techniques. Leaders in the profession share their insights and best practices to give you an overview of how arthroscopy and orthobiologics are used in foot and ankle surgery.

Each e-Book also features:

• Self-assessments after each chapter to help you earn CME credit
• Intuitive navigation
• Built-in notetaking and bookmarking tools

Visit acfas.org/e-learning to purchase the e-Books and watch This Week @ ACFAS for updates on new e-Book releases. Give your patients the tools they need to keep their feet and ankles healthy and safe all summer long. Download the following infographics from the ACFAS Marketing Toolbox for quick and easy patient education:

• Protect Your Feet from the Sun
• Keep Your Feet Safe at the Beach
• Prevent Foot & Ankle Running Injuries
• Pediatric Foot & Cleat Injuries
• Dos & Don’ts for Diabetic Foot Care

Print and display the infographics in your office or distribute them to your patients. You can also post them to your social media channels and practice website for maximum outreach.

Visit acfas.org/marketing for our complete infographics library and many other free resources you can use throughout the year to both educate your patients and promote your practice.

Foot and Ankle Surgery

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In this study, researchers examined whether age and body mass index (BMI) influence the outcome of patients after Achilles tendon reconstruction using the composite anterolateral thigh flap with vascularized fascia lata (ALT-FL flap).

Twenty patients with complex tissue defects involving the Achilles tendon underwent reconstruction with the ALT-FL flap. Both the Achilles tendon Total Rupture Score (ATRS) and the American Orthopaedic Foot and Ankle Society (AOFAS) score were assessed preoperatively and 12 months postoperatively. In addition, postoperative magnetic resonance imaging (MRI) studies and measurements of the ankle range of motion were performed.

All flaps survived, and MRI studies confirmed complete anatomical integration of the fascia lata as "neotendon" at the recipient site. Age did not correlate with the outcome measurements, while BMI showed significant negative correlation with the postoperative ATRS and AOFAS scores. The ATRS and AOFAS scores of all patients improved significantly. However, obese patients with a BMI of more than 30 kg/m² achieved significantly lower ATRS and AOFAS scores, as did patients with peripheral artery disease (PAD).

The researchers concluded that the ALT-FL flap enables reconstruction of complex tissue defects involving the Achilles tendon with positive functional results. However, the presence of an increased BMI or PAD, but not necessarily age, proves to be a predictor of poor clinical outcome and therefore should be considered carefully during patient selection.


The preferred method for calcaneal fracture treatment is open reduction and internal fixation (ORIF) using an extended lateral approach combined with plate osteosynthesis. However, this is associated with a wound complication rate of up to 30 percent. The aim of this study was to evaluate soft-tissue microcirculation of the hindfoot in healthy volunteers to determine influencing factors and to identify hypoxic or hypoperfused areas in nontrauma situations, with special attention to surgical approaches.

Researchers noninvasively measured microcirculation of the lateral hindfoot of 125 participants at 2 and 8 mm depths. Blood flow (BF) and oxygen saturation (SO2) of 10 measurement points (MPs) were documented. Demographic factors and regional differences with special regard to surgical approaches (extended lateral approach, Palmer approach, Ollier approach and a self-modified extended lateral approach) were analyzed.

The SO2 assessments at 2 and 8 mm depths revealed higher values in males, and there was a correlation of a BF lower 2 mm value and higher age. BF at the 2 mm depth was highest in the regions of Palmer and Ollier approach. The MP at the distal calcaneal tuberosity showed significantly higher values regarding all parameters, compared to the surrounding area.

The researchers concluded that in nontrauma situations, young males were associated with better microcirculatory supply of the lateral hindfoot. In addition, there was a trend for higher blood flow in regions of the Palmer and Ollier approach, and the distal calcaneal tuberosity was clearly superior in all microcirculatory parameters when compared to the surrounding area.


Researchers conducted this meta-analysis to compare different surgical techniques for management of chronic lateral ankle instability. They included seven randomized controlled trials of operative treatment for chronic lateral ankle instability for analysis. These fell in five clearly distinct groups.

One study comparing two different kinds of nonanatomic reconstruction procedures (dynamic and static tenodesis) found two clinical outcomes favoring static tenodesis: improved clinical satisfaction and less subsequent sprains. Two studies compared nonanatomic reconstruction versus anatomic repair. In one study, nerve damage was more frequent in the nonanatomic reconstruction group; the other reported that radiological measurement of ankle laxity showed that nonanatomic reconstruction provided higher reduction of talar tilt angle. Two studies comparing two anatomic repair surgical techniques (transosseous suture versus imbrication) showed no significant difference in any clinical outcome at the follow-up except operation time. One study compared two different anatomic repairment techniques and found that the double anchor technique was superior with respect to the reduction of talar tilt than single anchor technique. Another study compared an anatomic reconstruction procedure with a modified Brostrom technique. Primary reconstruction combined with ligament advanced reinforcement system results in better patient-scored clinical outcome, at two years postsurgery, than the modified Brostrom procedure.

The authors concluded that limited evidence exists to support any one surgical technique over another for chronic lateral ankle instability. However, they drew several conclusions from the evidence. First, there are limitations to the use of dynamic tenodesis, which obtained poor clinical satisfaction and more subsequent sprains. Second, nonanatomic reconstruction abnormally increased inversion stiffness at the subtalar level as compared with anatomic repairment. Third, multiple types of modified Brostrom procedures could acquire good clinical results. And finally, anatomic reconstruction is a better procedure for some specific patients.

Practice Management

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Employee embezzlement happens frequently in medicine, especially in small practices. This can result from employees creating fake companies, stealing petty cash or overstating hours worked, for example. However, practices can take steps to prevent embezzlement from occurring in the first place.

For medical practices to keep embezzlement at bay, conduct a detailed background check and drug testing on all employees—regardless of prior relationships with them. This includes a detailed credit check on any individual who will have access to money. It is important to note that many embezzlers have no criminal history. Furthermore, invest the time and resources in creating company policies and procedures and inform your staff that you take a zero-tolerance policy on theft, with all thefts to be reported to law enforcement. Additionally, create an office policy where staff members must provide all bills unopened to the practice's owners. Also consider having bills sent to the practice owner's home to prevent employees from tampering with billing statements. Finally, monitor cash copayments and review the cash brought in daily.

Any time you suspect that you are the victim of embezzlement, seek legal advice immediately. Your attorney should prepare a legal and investigation strategy, which should include working closely with your practice Certified Public Accountant, or with an outside forensic accountant.


Changes happen all the time across a range of payers, but unless practices regularly check their websites or read every email alert, things will be missed. Debbie Mackaman, RHIA, CPCO, CCDS, regulatory specialist for HCPro, urges providers to set aside time to monitor payer websites. "In reality, it is difficult to find time to keep an eye on all payer sites," she says. "On the other hand, CMS is easy to monitor once you know how to navigate their sites and what to sign up for to stay up-to-date. In most cases, there is a logical process to follow when researching Medicare questions."

For all the other payers, Mackaman has four tips for keeping up to date. First, read the notices, specifically by signing up for policy change notifications and email updates through a payer's website. Second, schedule regular reviews of payer websites. Engaging in "denials management" rather than "denials prevention" is a "costly approach," Mackaman says. Third, prioritize high-volume payers and high-volume services, and at the least, monitor those payers for changes. "Focus on services that have the highest negative financial impact if denied," she says. Finally, delegate this task to the most appropriate person and provide him or her with training and ongoing education.


When physicians leave a job, they typically have to purchase tail malpractice coverage, which provides protection for any claims filed after a claims-made policy has ended. The best tail insurance option for physicians depends on factors ranging from each practice's unique makeup and location to the exact procedures they were performing.

One unconventional option is a tail policy with lower limits than what physicians had on their claims-made policy. While the lower limits would reduce the overall cost of that policy, physicians should be aware that higher limits offer additional financial protection. Another way to save money when buying tail malpractice coverage is opting for a short-term—such as a one-year or three-year—tail malpractice policy. As time passes, the risk of having a claim filed against them declines, although this depends on the type of practice and procedures performed. A third option is a tail policy with aggregate limits that renew every year. Although this can increase the price of the tail policy, it will give peace of mind in securing renewing coverage.

Whichever tail malpractice coverage option physicians choose, they should always ensure that the coverage will exceed the potential exposures of their medical practice and the procedures performed. It is also recommended that physicians meet with a malpractice insurance agent to discuss all of their options.

Health Policy and Reimbursement

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The U.S. House of Representatives has passed bipartisan legislation to help address the nationwide opioid abuse epidemic. With a vote of 396–14, the bill is the broadest of several opioid-related measures passed by the House in recent weeks. "At a time when it seems we couldn't be more divided, it's clear that striking back against addiction is something that transcends politics and brings us together as a community, as a country and as a Congress," said House Energy and Commerce Committee Chair Greg Walden (R-OR), who has led the chamber's opioid efforts.

The legislation includes a number of measures to address the opioid epidemic, including lifting some limits on prescribing buprenorphine and requiring healthcare professionals to write prescriptions for Medicare beneficiaries electronically. While addiction advocates say the measures are good steps forward, they stress that more work and funding are necessary. The legislation is now expected to be sent to the Senate, which has also been working on opioid-related legislation.


Medicare is being revamped by Congress and the Trump administration to provide extra benefits to people with multiple chronic illnesses. The additional benefits can include social and medical services, home improvements like wheelchair ramps, transportation to doctors' offices and home delivery of hot meals.

The new law, the Chronic Care Act, has received support from both parties, as well as Medicare officials and insurance companies that operate the Medicare Advantage plans serving one-third of the 60 million Medicare beneficiaries. "This is a way to update and strengthen Medicare," said Sen. Ron Wyden (D-OR), an architect of the law. "It begins a transformational change in the way Medicare works for seniors who suffer from chronic conditions. More of them will be able to receive care at home, so they can stay independent and out of the hospital."

One-half of Medicare patients are treated for five or more chronic conditions each year, and they account for 75 percent of Medicare spending, according to Kenneth Thorpe, the chairman of the health policy department at Emory University. Under the new law and Trump administration policy, most of the new benefits will be reserved for Medicare Advantage plans, which will be able to offer additional benefits tailored to the needs of people with conditions like diabetes, Alzheimer's, Parkinson's disease, heart failure, rheumatoid arthritis and some types of cancer.


Sen. Lisa Murkowski (R-Alaska) is leading a push to ascertain how Congress could curb excessive out-of-network billing, as her state's attempted correction has only served to further hike healthcare costs. In 2004, Alaska released a little-known rule to check exorbitant bills for people with commercial insurance needing out-of-network treatment. The rule stipulated that insurers pay 80 percent of the reasonable market rate of the treatment, but it was mostly ineffective because unregulated specialists ran up prices. Murkowski said other rural states could face similar problems with too few specialists. As hospitals cannot afford to employ these doctors full-time, their services typically are out of network.

This problem narrowed debate at a Senate committee hearing on Sen. Lamar Alexander's (R-Tenn.) push to find policies to reduce healthcare costs. The Harvard Global Health Institute's Dr. Ashish Jha suggested, in Alaska's case, linking benchmark prices to a national average instead of to the local specialists' costs, which could drive incentives the other way. Panel witnesses called on lawmakers to weigh other transparency measures beyond out-of-network billing rules, criticizing the industry because beneficiaries are largely kept unaware in terms of cost of care and the coverage they can expect when they enter hospitals. Jha also noted that the U.S. Federal Trade Commission and other agencies responsible for monitoring antitrust issues as the industry consolidates need congressional support.

Medicine, Drugs and Devices

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Speaking at the American Diabetes Association (ADA) 2018 Scientific Sessions in Orlando, Darby Herkert, BS, from Yale University, reported on a study finding that patients in the $25,000 to $99,000 income bracket were significantly more likely to underuse insulin because of cost barriers. "We were shocked to find that 25.2 percent of patients surveyed were underusing insulin in some way in the past year due to cost, and we found this was common across different drug prescription plans," Herkert said. Those patients who underused insulin because of cost were found to have a threefold higher odds of poor glycemic control compared with those not underusing.

Carolyn Cox, RD, from Sharp Healthcare in San Diego and a delegate at the conference, said that patients struggling with the high costs of insulin are a common situation at her center. "Patients might go to the pharmacy and find that the [insulin] analog they are discharged on is extremely expensive, at $300 to $400 per vial," she noted. "These patients don't take insulin as prescribed, or not at all, but they don't have a prescription for anything else and end up being rehospitalized."

Herkert said that although prior studies have pointed to the potential role of medication cost in insulin underuse, to her knowledge there had not previously been research that examined cost-related insulin underuse, associated factors and subsequent effects.


Amid an opioid crisis, the medical community is seeking guidance on the appropriate pain prescription for patients after surgery. With no single right answer across the board, Johns Hopkins researcher and surgeon Marty Makary decided to look at the needs associated with specific operations. "It's mind-boggling to me," he says, "that so many opioid-prescribing guidelines do not specify the procedure. An ingrown toenail is not the same as cardiac bypass surgery."

Makary assembled a group of surgeons, nurses, patients and others late last year to brainstorm, eventually coming up with guidelines for 20 commonplace surgical procedures. Their recommendations include five to 10 opioid tablets following cesarean section, no more than 12 for some knee surgeries, up to 20 for open hysterectomy and a maximum of 30 for cardiac bypass. For others, like uncomplicated childbirth or cardiac catheterization, Makary and his team say opioids should be avoided altogether.

Although the guidelines theoretically could prevent patients from becoming chronic users or developing a dependence, while also keeping unused supply from ending up in the wrong hands, some lawmakers are going even further. About a dozen states have taken legal steps to limit the number of days' worth of opioids that can be prescribed for acute pain. Massachusetts allows up to one week of opioids, for example, with New Jersey restricting the supply to no more than five days. Depending on the state, Makary and others warn, patients could still be discharged with 50 or more opioid tablets.


A study published in Scientific Reports details the use of joint space mapping (JSM) to identify tiny changes in arthritic joints. The semi-automatic three-dimensional imaging algorithm was used to analyze images from standard computed tomography (CT) exams to spot changes in the space between each bone. The developers determined that their JSM algorithm outperformed the existing "gold standard" of x-ray-based joint imaging.

They say that once the algorithm's clinical utility is verified, this technique could mark a key improvement in quantitative analysis of joint disease as an alternative to two-dimensional radiographic imaging. The team also imagines that JSM could eventually be used to assess joint issues in the hips, knees and ankles of patients everywhere.