News From ACFAS

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Raise the bar on podiatric medical research—enter the College’s annual manuscript competition at ACFAS 2018, March 22–25, 2018 in Nashville.

You know better than anyone what it takes to lead the profession into the future. Help make sure this future shines brightly by submitting your latest research in manuscript format by September 15. All manuscripts submitted for consideration are blind-reviewed and judged on established criteria. Winners divide $10,000 in prize money.

Visit acfas.org for submission instructions. Listen to this month’s free podcast for insights on calcaneal fracture you won’t hear in a lecture hall. Moderator Glenn M. Weinraub, DPM, FACFAS, and four expert panelists share in a candid conversation about the biology and anatomy behind these fractures and how surgical approaches to treating them have changed. Learn how to best manage patient expectations and gain practical strategies for postoperative care.

Stay tuned for another new podcast to be released this weekend, and visit acfas.org/e-Learning each month for the latest additions to the ACFAS Podcast Library. Arthroscopy of the Foot and Ankle and The Art and Science of Orthobiologics for the Foot and Ankle, the College’s e-Books, are the perfect companions for a cross-country roadtrip or beachside vacation. Accessible from any device, these e-Books use full-color images and videos to guide you through surgical procedures and include inside perspectives from renowned experts in foot and ankle surgery.

Each e-Book features built-in notetaking and bookmarking tools to help you get the most from your reading. Short self-assessments after each chapter allow you to earn CME credit.

Vsit acfas.org/e-learning to purchase the e-Books and watch This Week @ ACFAS for updates on new releases. Everybody loves a makeover, and PodiatryCareers.org has been hard at work these past few months upgrading the ACFAS Career Center to make it easier on the eyes—especially on your mobile device. But these changes are more than skin deep! Your new Career Center now offers:

• Improved navigation
• Streamlined profile creation and updates
• Easily filtered job searches and alerts
• More employer information
• Easy application process

The site also provides a few tips on how you can make the most of the job search process, whether you are actively looking for a new job or just want to stay at the top of your career game. Check out the new PodiatryCareers.org, an ACFAS Benefit Partner, and start searching for jobs or potential candidates.

Foot and Ankle Surgery

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Researchers conducted a study to evaluate the effect of self-invented compound calcium phosphate cement on the proliferation and osteogenesis of bone mesenchymal stem cells (BMSCs). Four groups consisting of traditional calcium phosphate cement, modified calcium phosphate cement, modified calcium phosphate cement plus bone morphogenetic protein (BMP), and control group were established. Compared with other groups, the BMSCs in the modified calcium phosphate cement group presented with loose microstructure and the BMSCs closely attached to the vector margin. At seven days after co-culture, the expression of alkaline phosphatase (AKP) in the modified calcium phosphate cement plus BMP group was significantly unregulated compared to those in other groups. In the modified calcium phosphate cement group, the BMSCs properly proliferated on the surface of bone cement and invaded into the cement space. At 10 days, the expression levels of aggrecan, collagen I, collagen II, AKP and OSX mRNA in the modified calcium phosphate cement and modified calcium phosphate cement plus BMP groups were significantly upregulated than those in other groups. Researchers concluded that modified compound calcium phosphate cement possesses excellent biocompatibility and osteogenic induction ability. A loose microstructure and large pore size create a favorable environment for BMSCs' proliferation and vascular invasion, serving as an ideal vector for releasing BMP cytokines to mediate the differentiation and osteogenesis of BMSCs.


Mortality in patients with type 2 diabetes and diabetic foot osteomyelitis (DFO) has been examined in few small studies with a short follow-up. In this study, researchers sought to assess all-cause and cardiovascular mortality and predictors of mortality in a consecutive series of patients with DFO. Patients with a diagnosis of DFO attending the Diabetic Foot Unit of San Donato Hospital in Arezzo, Italy, between January 1, 2012 and December 31, 2013, were included in this retrospective study. Information on all-cause mortality up to December 1, 2016, was obtained from the registry of the Local Health Unit of Arezzo, which contains updated records of all persons living in Tuscany. A total of 194 patients were included in the study. During a mean period of observation of 2.8 years, 73 (37.6 percent) died, with a yearly rate of 13.2 percent. Of the 73 deaths, 59 were attributed to cardiovascular causes. After adjusting for possible confounders in a Cox analysis, site of osteomyelitis (hindfoot vs mid/forefoot) was associated with a higher mortality, and surgical treatment with a lower mortality. The researchers concluded that mortality in patients with DFO appears to be much higher than that reported in clinical series of patients with diabetic foot ulcers, particularly when the hindfoot is affected.


The surgical choice for grade 1 chondrosarcoma is debatable. Intralesional resection can minimize the damage caused by surgery and offer better functional outcome, but it is uncertain if it will result in higher rates of local recurrence and metastasis, fewer complications and better functional outcome compared with resection with wide margin. A systematic review and updated meta-analysis was conducted to compare intralesional resection and resection with wide margin in terms of local recurrence, metastasis, complications and functional outcome. Researchers comprehensively searched databases in December 2016 to identify studies comparing intralesional resection and resection with wide margin for central grade 1 chondrosarcoma. A total of 10 studies comprising 394 patients were examined, including 214 patients who had intralesional resection and 180 patients who had resection with wide margin for grade 1 chondrosarcoma. Intralesional resection was associated with lower complication rates and better Musculoskeletal Tumor Society score. There were no significant differences in terms of overall local recurrence; local recurrence based on adjuvant therapies; local recurrence in studies that included lesions of the hand, foot, pelvis and axial skeleton; and metastasis between groups. Intralesional resection provides lower rates of complications and better functional outcome with no significant increase in the risk of recurrence and metastasis, concluded the researchers, who believe it is a suitable treatment for central grade 1 chondrosarcoma.


Researchers conducted a prospective study to examine whether early functional exercise after surgery might have a secondary reduction effect on the subtalar joint, in particular the smaller fracture fragments that were not fixed firmly. From December 2012 to September 2013, patients with unilateral displaced intra-articular calcaneal fractures (DIACFs) were enrolled and received a treatment consisting of percutaneous leverage and minimally invasive fixation. After surgery, patients in the study group started exercising on days two to three, using partial weightbearing starting week three, and full weightbearing starting week 12. Patients in the control group followed a conventional postoperative protocol of partial weightbearing after week six and full weightbearing after the bone healed. Function was based on the American Orthopaedic Foot and Ankle Society (AOFAS) scoring scale at the 12^th postoperative month. In the study group, the differences between all studied time points were significant. Strong correlations were observed between the AOFAS score at postoperative month 12 and the maximal residual displacement of the fractures on the CT images at postoperative week 12. Early functional exercise and weightbearing activity can smooth and shape the subtalar joint and can reduce the residual displacement of the articular surface, improving functional recovery of the affected foot, the researchers say, recommending early rehabilitation functional exercise in clinical practice.

Practice Management

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Strategic consultant Laurie Morgan says teamwork is essential to physicians maximizing their performance, and she notes practice owners who willfully create opportunities for them and their physicians to connect can benefit in many ways. Morgan says teaming up with a mentor can help new physicians become productive faster, and encouraging all physicians to connect as a team helps them continue learning while avoiding inefficiencies. Another advantage is accelerated problem-solving, as regular physician meetings, email groups and other tools to keep physicians linked can tear down silos and reinforce a sense of teamwork. Likewise, the practice's culture and morale can be elevated through teamwork. Consciously supporting a shared culture also helps guide the patient experience and engage employees more fully. It can also help with the hiring process by making it less difficult to characterize the elusive quality of "fit."


Mobile technology can streamline many daily tasks of physicians, but also place greater demands on them. Bryan Vartabedian at Texas Children's Hospital in Houston sees such technology as transformational, noting an emergency medical records system used by his hospital, coupled with a smartphone app, grants him nearly full access to all his patient records, scheduling and more. "Having immediate access to the Internet in an exam room is quite helpful in circumstances where I need an immediate reference," Vartabedian says. He also says mobile technology gives patients more opportunities to interact with their physicians than ever before. This can be both a blessing and a curse in the form of more physician availability and greater demands from patients for immediate answers to their queries. Vartabedian expects mobile technology to be even more tightly intertwined with healthcare in the future, and as consumers increasingly adopt technology, they will be able to learn and do more on their own initiative, especially as software gets better at helping people interpret their own medical data. This may cause the roles of advanced practitioners or health coaches to expand.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services has issued a final rule that could put physicians at risk of not getting paid for services provided to patients covered under the Affordable Care Act (ACA). The rule calls for patients to pay past due premiums before reenrolling in any of an exchange insurer's products. At issue for physicians is that the ACA allows certain enrollees a three-month grace period to remain enrolled if they have not paid their premium, yet plans to stop payments on claims after one month. Physicians can be rendered unable to collect from the insurer for two months of claims if the debt is never cleared. The grace-period provision, which is given to enrollees receiving advance premium tax credits, applied to an estimated 9.4 million enrollees in 2016, according to the Kaiser Family Foundation. American Medical Association President Dr. Andrew W. Gurman says regulations "still need to address the resulting inequity of the ACA's grace period, which allows issuers to collect unpaid premiums for months in which healthcare services were provided but not actually covered by insurance."


Many Republican governors are urging Republican senators to push back on the current healthcare legislation because it would cut Medicaid funding. Governors of states, including Ohio, Nevada and Arkansas, which stand to lose billions of dollars in Medicaid funding under the Senate bill, want senators to keep as much of that money as possible. The bill would phase out that expansion and transform the state-federal safety net program into one in which the federal government's share would be capped. In all, the bill would cut $772 billion in funding for the program over a decade. "It's a pretty big deal, because in most cases these states have had bitter battles inside the state legislature and [with the] governor about [Medicaid], and it’s been settled in favor of expansion," says Stewart Verdery, a former GOP Senate aide and founder of Monument Policy Group, a lobbying and public affairs firm. Republicans have said they want to give states more flexibility in how they spend federal dollars on Medicaid in hopes they can come up with innovative ways to stretch the money. Some health analysts and lawmakers from both parties say that approach would be overwhelmed by the bill’s steep cuts, which would likely force states to limit eligibility or reduce benefits.


The Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) promises to reshape how Medicare pays physicians under the Quality Payment Program (QPP). Yet, a survey of 1,000 practicing physicians who have been involved in practice decision-making related to QPP shows that fewer than one in four physicians feel well prepared to meet its requirements in 2017, according to a survey by the American Medical Association (AMA) and KPMG LLP, the U.S. audit, tax and advisory firm. "This survey showed that about a third of respondents are unlikely to meet the basic standard of one patient, one measure, no penalty. To help physicians meet that standard, AMA developed and deployed resources to guide physicians toward compliance," said AMA President David O. Barbe. "In just 10 steps, physicians can successfully meet the standard under MACRA. Those who are prepared to report more data can realize rewards for improvement and for delivering high-quality, high-value care."


With the U.S. Centers for Medicare and Medicaid Services (CMS) planning to start sending new Medicare cards to beneficiaries in April 2018, healthcare providers must be ready for the switchover. CMS will strip Social Security numbers from Medicare cards and instead assign them random numbers called Medicare Beneficiary Identifiers (MBIs). The agency says all Medicare cards will be replaced by April 2019, but providers' systems must be able to accept the new MBI format by April 2018. CMS offers a five-step process for providers to prepare for the transition, beginning with paying a visit to the Medicare Learning Network (MLN) to access educational materials about CMS' programs and policies and to sign up for the agency's weekly MLN Connects newsletter. The second recommended step is for providers to attend CMS' quarterly calls to hear updates and continuing information about the Social Security Number Removal Initiative. Step three is to confirm all Medicare beneficiaries patients' addresses, and if the ones on file differ from the address on electronic eligibility transactions, ask beneficiaries to contact Social Security to update their records. The next step has providers educating beneficiaries about the new cards, and the final step is to test changes to their systems and coordinate with billing office staff to ensure readiness for the new MBI format.

Medicine, Drugs and Devices

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New data from the U.S. Centers for Medicare and Medicaid Services shows that payments from drug makers and medical device manufacturers to physicians and hospitals increased slightly last year. According to the Open Payments Data, the companies paid doctors and hospitals $8.18 billion in 2016, up from $8.09 billion in the previous year. Of the total for 2016, $4.6 billion went toward research, while $2.8 billion was allocated for general payments, and the remainder went to ownership or investment interests. The data shows that nearly 80 percent of the money went to services, consulting and royalties. More than 20 percent of overall payments went to food and beverage, travel and lodging. The Open Payments Data aims to create public transparency about financial ties between physicians, teaching hospitals and manufacturers, as well as to identify wasteful spending and the influence drug and device makers have on care, education and research.


Discussions between physicians and patients concerning medication costs can often lead to less financially onerous prescriptions and better adherence to drug regimens. This conclusion is based on a poll of 2,131 people, divided almost equally between people 50 to 64, and those 65 to 80. The survey found 27 percent of adults 50 to 80 years old described their prescription drug costs as financially taxing. In addition, one-sixth of respondents took six or more prescriptions and saw more than one physician. Meanwhile, 49 percent of those who said drug costs were burdensome had not talked to their physicians about the cost of their prescriptions. Furthermore, 67 percent of those who did talk to their physician about cost got a recommendation for a less expensive drug, while 37 percent received similar recommendations from pharmacists. "We encourage patients to speak up during their clinic visits, and when they're at the pharmacy, and ask about ways to reduce the cost of their prescriptions," says University of Michigan Professor Preeti Malani. "But equally, we see a need for health professionals to find ways to more routinely engage with patients about cost—especially through formal medication reviews such as the one that Medicare will cover."