News From ACFAS

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Put your latest research front and center—submit your manuscript to the annual manuscript competition at ACFAS 2020, February 19-22, 2020, in San Antonio. Manuscript entries are due by August 15, 2019.

Submissions are anonymously reviewed and judged on established criteria. Winners will divide $10,000 in prize money supported in part by a grant from the Podiatry Foundation of Pittsburgh.

Take advantage of the opportunity to share your latest discoveries with your peers—visit acfas.org for submission criteria and guidelines.
Plan to attend ACFAS Residents' Day set for February 18, one day prior to ACFAS 2020 in San Antonio.

This popular day-long seminar provides real world tools to help you move to practice successfully. Experienced foot and ankle surgery faculty will share their first-hand experiences and insight from their own early years of practice.

Make plans to attend and watch ACFAS publications and acfas.org in the coming months for registration information.
Whether you listen to podcasts, prefer to read an eBook, or would rather watch a video—we have it all. Explore a variety of learning mediums and hundreds of unique educational experiences and earn CMEs at the ACFAS e-Learning Portal.

Up Next:

Clinical Sessions

• July — The 2nd Ray: Knowns and Unknowns (YMR)

Podcasts

• August — Team Approach to Diabetic Limb Salvage

Visit acfas.org/e-learning. It's ready when you are.

Foot and Ankle Surgery

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A controlled laboratory study finds altered kinematics and persisting ankle instability may be associated with degenerative changes and osteochondral lesions. The study examined the effect of ligament reconstruction surgery with suture tape augmentation on foot-ankle kinematics during simulated gait. The study tested five fresh-frozen cadaveric specimens in five different conditions: intact, isolated anterior talofibular ligament (ATFL) rupture, combined ATFL and calcaneofibular ligament (CFL) rupture, ATFL-CFL reconstruction and ATFL reconstruction. For each condition, researchers calculated the range of motion (ROM) and average angle in the hindfoot and midfoot joints during the stance phase of normal and inverted gait.

The ATFL-CFL reconstruction showed better restored motion immediately after surgery than isolated ATFL reconstruction after a combined ATFL-CFL rupture. The findings show ligament reconstruction with suture tape augmentation can partially restore kinematics in the hindfoot and midfoot at the time of surgery. In clinical applications, following the classic Broström-Gould technique with suture-tape augmentation may protect the repaired ligament during healing by limiting excessive ROM after a rupture.


A new study indicates that extracorporeal shock wave therapy combined with a home exercise program may be beneficial to patients with Achilles tendinopathy, both insertional and noninstertional. The prospective case study examines the outcomes of 39 patients following this regimen, with an average follow-up period of 163 days. The regimen demonstrated significant benefits in pain, stiffness, and a range of measures of local and global function. For patients with insertional Achilles tendinopathy, median values for self-reported pain improved from a baseline of six and a half out of 10 to two out of 10 at six months. For patients with noninstertional Achilles tendinopathy, pain improved from seven out of 10 at three months to six out of 10 at six months. Despite improvements in pain and function, physical activity levels did not increase following the treatment.


New research rates the reproducibility of ankle stability assessment and compares it with the classification by Lauge-Hansen and Arbeitsgemeinschaft für Osteosyntesefragen (AO) in adult patients with primary ankle fractures. In a double-blinded study, two medical students, two residents, and one consultant in orthopedic traumatology were asked two times to review X-ray images of a total of 496 consecutive ankle fractures. Using unweighted Kappa statistics to assess reproducibility, the study found that the stability assessment has substantial to almost-perfect agreement, which is comparable to the Lauge-Hansen and AO classifications.

Practice Management

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In April 2019 the Department of Justice (DOJ) Criminal Division issued guidance entitled “Evaluation of Corporate Compliance Programs,” which included some factors prosecutors consider in the event of a criminal investigation or indictment. These include “the adequacy and effectiveness of the corporation's compliance program at the time of the offense,” as well as its remedial efforts to implement or improve a corporate compliance program.

A memorandum entitled “Selection of Monitors in Criminal Division Matters” instructs prosecutors to consider whether a corporation has invested in and improved its corporate compliance program and internal controls systems. As the DOJ cracks down on false claims, physicians and providers can take several steps to mitigate the risk of a False Claims Act case and/or criminal investigation. These include conducting internal audits on billing and coding, auditing corporate books and records, utilizing enterprise risk management, confirming no kickbacks are being paid or received and ensuring the analysis includes testing mechanisms.


Rising deductibles and cost-sharing requirements in health plans have more patients looking to talk with physicians about healthcare costs. According to a survey by Avalere Health, 76 percent of patients felt it was important to discuss cost but 21 percent said they receive some, little or no information during a doctor visit. Until recently physicians have been reluctant to talk about costs because they were uncertain about prices, thought the discussion would take too much time and were unaware of resources that could help patients. However healthcare industry experts say it is important for doctors to bring up cost of care because patients do not always think they can talk about it.

Physicians should consider the topic to be fair game with every patient, says Emmy Ganos, Ph.D., program officer at the Robert Wood Johnson Foundation (RWJF). To create a welcoming environment for patients who feel ashamed to raise the issue, doctors can use language such as "a lot of my patients have trouble affording medications. Has that been an issue for you?" Ganos adds. RWJF and Avalere's Cost Conversation project offers a series of practice briefs, including resources on medication discount programs, available at America's Essential Hospitals website.


When training nurses, organizations and leadership development must emphasize the importance of active listening, which can heavily impact patient care compliance, Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) scores and an organization’s financial health. A new study draws from patient experiences to characterize strong and weak active listening in nurses. Patients praised nurses who made them feel distinct from other patients—practicing behaviors such as eye contact, sitting, body language and attending to individual patient care preferences. Patients also appreciated nurses who put them at ease by narrating care, anticipating and answering questions, giving reassurance, passing along information, noticing patient body language and including family in discussions.

In terms of negative behaviors, patients complained about nurses who seemed “arrogant” by exhibiting sarcasm, being rude, doubting patients, speaking in a language the patient does not know and blaming others for unfulfilled responsibilities. Patients also complained about behavior suggesting insensitivity or an abuse of power, such as discounting or making light of patient concerns, arguing with the patient, rejecting their input, refusing to clarify orders and standing at a distance from the patient. Patients also felt ignored when nurses appeared rushed or scattered and when they failed to perform basic elements of care.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) has delayed full implementation of its prospective edits to Medicare outpatient payment system claims for services provided by hospitals and health systems. The system edits apply to outpatient, provider-based, off-campus departments and require providers to include the provider address for services rendered as the one entered in the Medicare Provider, Enrollment, Chain and Ownership System for that location. These edits will now take effect on October 1, rather than in July as initially planned. CMS said it has completed round 3 testing, which was to ensure hospitals and health systems have used the new practice location screen tool and updated claim submission as needed. While the agency said it has not discovered any major issues in analyzing data from the testing, the agency has decided to extend its review process and delay full implementation in response to stakeholder comments.


Seeking ways to address chronic pain without narcotics, Medicare is exploring the possibility of covering acupuncture as a treatment for lower-back pain only. The U.S. Department of Health and Human Services said it hopes to determine if acupuncture is “reasonable and necessary” under the Medicare program, with a proposal due by July 15 and a final decision by October 13.

Medicine, Drugs and Devices

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U.S. Food and Drug Administration (FDA) records show that since President Donald Trump assumed office the number of FDA warning letters targeting ineffective or harmful drugs, devices or foods has declined by a third. FDA records from January 20, 2017, through May 22, 2019, reveal the agency issued 1,033 warning letters, compared with 1,532 for the most recent equivalent period under the Obama administration. Warnings from the FDA's Center for Devices and Radiological Health, which helps ensure the safety and quality of medical devices and from some of the agency's district offices have fallen by more than two-thirds. Two of the district offices have not issued a warning in more than two years.

Meanwhile, FDA inspection reports labeled "official action indicated," which indicate potential warning letters or similar actions, fell by about 50 percent under Trump and are continuing to trend downward when measured against the end of the previous administration. The only significant exception to the downward trend on warning letters is the FDA's Center for Drug Evaluation and Research, which has issued 188 warnings under Trump compared with 116 in the most recent period under the Obama administration. Many of the Trump-period letters involve sales of opioids as well as over the counter and generic drugs made in China and India.


Educating patients and physicians about safe antibiotic use can reduce overuse by a third, according to new research involving urgent care centers and emergency departments in California and Colorado. The study looked at two approaches aimed at helping doctors make better antibiotic-prescribing decisions for viral acute respiratory infections. One method involved offering educational materials from the U.S. Centers for Disease Control and Prevention's Be Antibiotics Aware campaign as well as an on-site physician champion. The second more intensive method provided education and behavioral "nudges," including physician feedback on prescribing rates, comparisons with colleagues and public commitment to decrease unnecessary use. The study was published in Academic Emergency Medicine.


A new study in Health Affairs associates an above-average number of electronic health record (EHR) system-generated messages with physician burnout symptoms. The study draws on administrative and EHR data from a health center in California as well as a survey of 934 physicians at that center asking about burnout and intent to reduce clinical work time. Researchers also used administrative and EHR data from the same center to investigate several explanatory variables, including data about in-basket messages. The researchers found physicians received on average 243 in-basket messages per week, 47 percent of which came from the EHR system, including pending automatic orders, health maintenance reminders and requests for prior authorization. Forty-five percent of physicians with burnout symptoms received greater-than-average numbers of system-generated in-basket messages while only 29 percent with burnout symptoms received average or less-than-average amounts.