News From ACFAS

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Don’t miss your chance to be part of the College’s prestigious annual manuscript competition at ACFAS 2019, February 14–17, 2019 at the New Orleans Convention Center. Manuscript entries are due by August 15, 2018.

All manuscripts submitted for consideration are blind-reviewed and judged on established criteria. Winners will divide $10,000 in prize money supported in part by a generous grant from the Podiatry Foundation of Pittsburgh.

Visit acfas.org for submission guidelines and criteria, and take advantage of this opportunity to share your latest discoveries with your peers! Last call for This Week content reviewers! Volunteer to help ensure the abstracts featured in each issue of This Week @ ACFAS are timely and accurate.

As a content reviewer, you will receive a This Week @ ACFAS preview every Friday so you can check the abstracts listed under Foot and Ankle Surgery, Practice Management, Health Policy and Reimbursement, and Medicine, Drugs and Devices. Send your changes and input to ACFAS staff, and we will incorporate them into the e-newsletter.

Contact Melissa Matusek, CAE, ACFAS director of Marketing and Communications, at (773) 444-1306 if you would like to serve as a content reviewer and help us make This Week @ ACFAS the best it can be! It’s never too early to start looking for your first foot and ankle surgical job! PodiatryCareers.org, the ACFAS Career Center, can help. Access the site to view all available positions and to sign up for job alerts so you never miss a new opportunity. Also find tips on how you can make the most of your job search process and stay on top of your career game.

Employers: are you looking to add someone fresh out of residency, with the latest surgical skillset, to your practice? Post a job or browse resumes of potential candidates to help accelerate your search and aid in the hiring process.

Visit PodiatryCareers.org, an ACFAS Benefit Partner, to start your search today! Your time is valuable, and it should not be spent sorting through hundreds of medical specialty journals to stay ahead of the latest research. Tap into ACFAS’ monthly Scientific Literature Reviews (SLRs) for short, digestible summaries of studies covering the newest developments in foot and ankle surgery.

Visit acfas.org/SLR to read the July SLRs, which focus on osteochondral lesions, hallux valgus deformity, diabetic foot infection and more. Each SLR is written by a podiatric surgical resident and includes podiatric relevance, methods, results and conclusions. For an even deeper look at how foot and ankle surgical research has evolved over the past decade, explore the SLR archive for studies dating back to 2009.

Foot and Ankle Surgery

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This study sought to assess clinical healing and radiographic outcomes for patients treated with a perioperative ketorolac regimen after open reduction and internal fixation (ORIF) of ankle fractures.

A retrospective review was performed on all patients who received perioperative ketorolac at the time of lateral malleolar, bimalleolar and trimalleolar ankle ORIF by a single surgeon between 2010 and 2016 with minimum four months follow-up. Patients received 20 tablets of 10 mg ketorolac Q6 hours. Radiographs were evaluated independently by two blinded fellowship-trained orthopaedic foot and ankle surgeons to assess for radiographic healing. A total of 281 patients were included, with a median age of 51 years and 138 males (47 percent). Statistical analysis consisted of a linear mixed-effects regression.

In all, 94 percent of patients were clinically healed within 12 weeks, and 92 percent were radiographically healed within 12 weeks. Within the group of patients who did not heal within 12 weeks, mean time to clinical healing was 16.9 weeks, and mean time to radiographic healing was 17.1 weeks. In patients taking ketorolac, there were no cases of nonunion in the series and no significant difference found between fracture patterns and healing or complications.

Perioperative ketorolac use was associated with a high rate of fracture union by 12 weeks. Additional studies are necessary to determine whether ketorolac helps reduce opioid consumption and improve pain following ORIF of ankle fractures.


Minimal literature evaluates irrigation and debridement (I&D) and polyethylene exchange with component retention for acute hematogenous periprosthetic joint infection (PJI) in total ankle arthroplasty (TAA). The purpose of this study was to evaluate both the clinical and patient-reported outcomes and survivorship of TAA acute hematogenous PJIs treated with I&D and polyethylene exchange.

Researchers conducted a single-center, retrospective chart review of prospectively collected data in 14 patients with TAA PJI who subsequently underwent I&D and polyethylene exchange with retention of metal components. The primary outcome was failure rate of I&D and polyethylene exchange, where failure was defined as subsequent removal of all components and two-stage revision or arthrodesis. Patient-reported outcomes collected before primary arthroplasty, after primary arthroplasty and after polyethylene exchange were also analyzed.

The researchers concluded that I&D and polyethylene exchange with retention of metal components has a long-term survivorship comparable to those reported in the total knee and total hip arthroplasty literature. Patient-reported outcomes after I&D and polyethylene exchange were comparable to those collected after primary arthroplasty in those patients who ultimately retained their implants. Two variables in this cohort associated with I&D and polyethylene exchange failure included time the patient was symptomatic prior to I&D as well as organism isolated on culture. With a failure rate of 54 percent, the authors recommend thorough evaluation on a case-by-case basis prior to indicating a patient for single-stage I&D with polyethylene exchange.


With ankle arthritis often affecting young patients, joint-sparing treatments instead of total joint replacement should be considered. In this study, researchers analyzed the stability of different implants and their appropriateness for supramalleolar osteotomies (SMOTs).

Twenty-five bone models (Sawbone Europe, Malmö, Sweden) were used for biomechanical testing. SMOT was performed as a uniplanar osteotomy, leaving 5 mm of lateral bone intact with a standardized gap of 8 mm. Five different plates commonly used for SMOT were assessed. For axial stability, the constructs were tested during 100 cycles for each load (150N and 800N) at a rate of 0.5 Hz. For rotational stability, each construct was subject to 100 cycles of 5 Nm torque at a rate of 0.25 Hz, performing three runs with an axial preload of 0N, 150N or 800N. Ultimate axial load was performed for one half, and ultimate rotational load was performed for the other half of the constructs. In addition, the stiffness of the different constructs after failure was tested.

All constructs showed high stability and could be tested until maximum cyclic load. No significant difference existed between the five plates, neither for stiffness (axial or rotational) nor for failure load (axial or rotational). One plate indicated superiority in axial failure testing without any significant difference.

The researchers concluded that all implants could be tested until maximum load. The intact hinge seems to provide sufficient support to compensate for lower moment of inertia of some plates.

Practice Management

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Engaging millennials is increasingly important for physician practices looking to maintain or expand their market share. Over the past decade, there has been a shift away from the primary care and hospital setting preferred by baby boomers, according to Louis Levitt, MD, vice president of The Centers for Advanced Orthopaedics in Bethesda, Md. Levitt is revamping his practice, Orthopaedic Medicine and Surgery Care Center in Washington, DC, to cater to millennials' desire for convenience and affordable care. The practice has taken four approaches.

First, making a practice accessible online is vital to attracting millennial patients, Levitt says. His office has prioritized online booking, offered online tools to ease administrative burdens and used social media to advertise to and engage millennials. Second, Levitt recommends offering a convenient location. His practice has opened its first satellite office in 35 years to help provide easy access for millennials.

Third, ensure good patient experience, which means focusing on the efficient use of patient time. "We have gone to great lengths to cut down on the wait times and any other difficulties getting into the office," Levitt says. Practices are no longer judged on healthcare alone, according to Levitt, but on the entire patient experience. Finally, to appeal to millennials, established physician practices must be willing to embrace new ideas and approaches to providing care, Levitt says.


Tablet-based platforms have the potential to increase patient engagement and deliver measurable return on investment. For instance, replacing paper forms using a tablet-based registration platform enables standardization across the organization. As a result, forms can be administered in multiple languages and in 508-compliant font sizes, as well as be presented individually based on location of services and financial classes.

When tablets are integrated with the finance and billing systems, making a payment at the point of service is easy for both patients and staff. Meanwhile, delivering correct patient information on claims is essential. Verifying that the right insurance is on file increases clean claim rates by 22 percent. Platforms that establish bidirectional data exchange with document management, scheduling, billing and EMR systems act as an overlay of operational automation to a potentially cluttered HIT. With a tablet technology platform, metrics are automatically collected each time a patient or staff uses the system—by location, demographic, time of day and more. Access to dashboard reports with aggregated metrics provides visibility to daily operations and long-term trends. Mobile solutions offer the ability to connect and offer a consistent digital experience across the entire patient experience.


Improved reporting can drive higher performance of physicians' medical practice, specifically collection rate, days in accounts receivable (A/R) and accounts receivable aging. If a medical practice sees unacceptably low net collections for a particular payer, it may consider alternatives, such as requiring patients to pay up front for services or renegotiating payer contacts.

The industry benchmark for days in accounts receivable is typically 30 days, but this can vary by type of specialty and payer mix. The majority of practice management applications have built in capability to run a report for the desired timeframe, namely monthly, quarterly or yearly. They can also generate an A/R aging report that breaks down claims based on the number of days they have been unpaid, totaled by payer. This helps identify potential issues and prioritize how best to manage the A/R follow-up by dollar amount and by payer. Days in A/R and A/R aging demonstrate a practice's ability to quickly turn over A/R and collect all money due.

The bottom line is that practices cannot know where they are going until they know where they are. These measures are just the start to uncovering a wide range of information that will put providers on the path to higher medical practice performance.

Health Policy and Reimbursement

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Industry groups have written 300 pages of comments urging Congress to take action on medical device security in response to a House Energy and Commerce Committee request for information. Along with requesting financial support and guidance, their comments call on the U.S. Food and Drug Administration (FDA) to coordinate medical device vulnerabilities and to set standards on postmarket cybersecurity.

The American Hospital Association (AHA) warned that hospitals' efforts to strengthen cybersecurity are hampered by the vulnerabilities posed by medical devices running on legacy systems, often a key entry point for hackers. Meanwhile, simply updating the legacy technology is not financially feasible for many hospitals, AHA officials wrote.

In its comments, the American Alliance of Orthopaedic Executives estimated that the cost of cybersecurity upkeep was about $60,789 per practice. The group proposed that those costs could be lowered with federal assistance, which would include incentivizing adherence to security policy updates.

Meanwhile, AHA officials also said that a single source of information around device security, coordinated disclosures and timely patches could help hospitals manage the plethora of device manufacturers on their systems—which could be coordinated by FDA. In addition, FDA must also go beyond pre and postmarket guidance and make security required for legacy devices since there is no financial incentive to do so and the issues have yet to be resolved, AHA officials argued.


The U.S. Centers for Medicare and Medicaid Services (CMS) wants to roll out a demonstration to test the concept of waiving Merit-Based Incentive Payment System (MIPS) mandates for clinicians who participate in certain Medicare Advantage plans that involve assuming risk. The Quality Payment Program (QPP) established by the Medicare Access and CHIP Reauthorization Act stipulates that clinicians currently participate in the QPP either via MIPS, which adjusts Medicare payments based on combined performance on measures of quality, cost, improvement activities and advancing care information or via Advanced Alternate Payment Models (APMs), which requires clinicians to assume risk for what is spent for their beneficiaries' healthcare.

CMS says certain Medicare Advantage plans are developing innovative arrangements that resemble Advanced APMs, but without undertaking the agency's proposed Medicare Advantage Qualifying Payment Arrangement Incentive demonstration, doctors are still subject to MIPS even if they participate extensively in such arrangements.


A study published in PLOS Medicine found that Medicare Advantage (MA) enrollees spend less time in nursing communities after surgery and are less likely to go back to the hospitals compared with those in traditional Medicare. The researchers determined that MA enrollees spent five fewer days in skilled nursing communities on average and had 463 fewer minutes of rehabilitation therapy for hip fractures. MA enrollees also were less likely to go back to hospitals, less likely to become a long-term resident at a nursing community and more likely to remain in their communities after release from rehab compared to fee-for-service Medicare beneficiaries.

Medicine, Drugs and Devices

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A new report from the European Molecular Biology Laboratory in Germany suggests that combining certain antibiotics could be more effective against dangerous bacteria. Researchers report in Nature that they tested 3,000 different combinations of antibiotics with each other or with drugs, food additives and other compounds on several common types of bacteria. They found hundreds of combinations that increased the effects of antibiotic treatment. Compared with combinations of drugs that worked in different ways, drug pairs that focused on the same cellular processes were more likely to be successful, the researchers note. The study revealed that a number of the interactions were species-specific—working well against one kind of bacteria, but not another—and some combinations effectively treated bacteria that is resistant to several other antibiotics, in cell models as well as moth studies.


Emergency departments (EDs) across the country have been struggling with shortages of essential drugs, including pain and heart medications. As a result, some patients end up suffering through their pain, while others risk reactions to alternative medications that may not be the best option. "So many substances are short, and we're dancing every shift," said James Augustine, MD, a doctor in Cincinnati who works for US Acute Care Solutions, which employs doctors who work in EDs for hospitals around the country.

While previous drug shortages were often dealt with behind the scenes by pharmacists, physicians and nurses, doctors say the current shortages are more directly affecting care for patients. According to a May survey of emergency doctors by the American College of Emergency Physicians, 90 percent said they lacked access to vital drugs, and almost 40 percent said patients had been negatively affected.

Benjamin Savitch, MD, who oversees the ED at Norwegian American Hospital in Chicago for US Acute Care Solutions, noted the difficulty in explaining the situation to patients. "They are often disappointed and frustrated that the system is not functioning at the level it should," he said. Drug giant Pfizer has said that manufacturing problems at some of its facilities will reduce supplies of many of its products, including morphine, until 2019. Meanwhile, the company's competitors are struggling to keep up with demand and are depleting their own supplies.

Additionally, the shortage of opioids has been affected by federal quotas that limit the amount of narcotics any one company can produce. While the U.S. Food and Drug Administration has made some progress, says Commissioner Scott Gottlieb, the agency is working to address the underlying issue in which drug companies earn a narrow margin on products that are difficult to make. "Today it's one drug, tomorrow it will be another drug," Gottlieb said. "We've got to think of something more holistic and comprehensive."


Experts warn that the nation's troubled drug pricing system is compelling some patients to make decisions that can adversely affect their health. Sameer Awsare, MD, an internist and associate executive director for The Permanente Medical Group, recalls that one of his congestive heart failure patients wound up in the emergency room because of inadequate care management. The patient had been taking her medications every other day because she was unable to afford them, says Awsare, who spoke at a recent online event on drug prices hosted by the Alliance for Health Policy.

Some patients are also turning to purchasing medications from overseas. Dora Hughes, MD, a senior policy adviser at Sidley Austin LLP, says the U.S. Food and Drug Administration (FDA) has unveiled several initiatives designed to raise competition in drug markets. "[Commissioner Scott Gottlieb] startled stakeholders with fairly tough talk," she said. "This has certainly not been the traditional role or focus of FDA."