News From ACFAS

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Submissions for the Manuscript Competition at ACFAS 75 in Las Vegas are due August 15, 2016. Don’t miss your chance to be part of this historic conference and to share your latest research with your colleagues.

All manuscripts submitted for consideration will be blind-reviewed and judged on established criteria. Winners will divide $10,000 in prize money.

Visit acfas.org/asc for manuscript requirements and submission guidelines. Bring your research to a wider audience through Open Access publishing in The Journal of Foot & Ankle Surgery (JFAS). JFAS now offers two ways to publish your research—the traditional “subscription” route and now a new Open Access option. Open Access makes your research available online without price or permission barriers to non-subscribers of the Journal. Readers will have free, immediate and permanent access to your article through ScienceDirect, which means more exposure for your research.

ACFAS members receive a 25 percent discount on the cost for Open Access publication. For more information on Open Access publishing in the Journal or to submit your article, visit the Journal’s Open Access page. Take a not-so-straightforward approach to common complex revisions—register now for Comprehensive Reconstruction of the Foot and Ankle, September 24–25 at the MedCure Surgical Training Center in Portland.

You’ll spend more than 75 percent of your time in a state-of-the-art, hands-on lab performing the latest reconstructive and salvage procedures under expert instruction. Informal and case-based discussion with faculty and your fellow attendees will give you new strategies for managing the unexpected.

This course also includes a fireside chat during and after dinner on Saturday evening. Bring radiographs of your most challenging case on a flash drive or CD to share with participants and get their feedback.

Space is limited to 48 people, so visit acfas.org/education to register today.

Foot and Ankle Surgery

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A controlled laboratory study was conducted to evaluate ankle plantar flexor and toe flexor muscle performance of individuals with plantar heel pain through use of clinically feasible measures and to study how muscle performance and duration of foot orthosis use relate to each other. The researchers employed the rocker board plantar flexion test (RBPFT) and modified paper grip test for the great toe (mPGTGT) and lesser toes (mPGTLT) to assess foot plantar flexor muscle performance in 27 subjects with plantar heel pain compared to a control group without foot pain matched according to age, sex and body mass. Versus the control group, individuals with plantar heel pain exhibited lower performance in the RBPFT, the mPGTGT and the mPGTLT. Longer duration of foot orthosis use was moderately correlated to lower performance on the RBPFT, the mPGTGT and the mPGTLT.


A study was conducted to probe the impact of visual cues provided by exposing the dorsum of the foot and marking the dorsalis pedis pulse, using a clinical model where the researchers compared the quality of the recorded clinical examination undertaken by 30 nurses. The nurses were randomly assigned to evaluate a patient with either a traditional back-slab or one in which the dorsal bandaging had been cut back and the dorsalis pedis pulse marked. The quality of the recorded clinical examination was substantially improved in the cut-back group. Previous studies have demonstrated that the cut-back would not reduce the effectiveness of the back-slab as a splint. The researchers concluded that all tibial back-slabs should have the bandaging on the dorsum of the foot cut back and the site of the dorsalis pedis pulse marked, which should improve the subsequent clinical examinations undertaken and recorded without altering the back-slab's efficacy as a splint.


A study was conducted to investigate long-term outcomes of neglected achilles tendon rupture repair with gastrocnemius flaps. Twenty-one neglected achilles tendon rupture reconstructions were performed using gastrocnemius fascial flaps between 1995 and 2005. Average age was 32.1 years, while average period between rupture and operation was 8.4 weeks. Ankle range of motion, calf circumference, heel raise test, Visual Analog Scale (VAS), American Orthopedic Foot and Ankle Society (AOFAS) hindfoot and Foot and Ankle Disability Index (FADI) scores were checked. The median gap length was 6.4 cm. Median follow-up was 145.3 months. Average dorsiflexion/plantar flexion values for operated and uneffected sides were 18 degrees/30 degrees and 19 degrees/30 degrees, respectively. The median values for AOFAS and FADI scores were 98.5 points and 98.9 percent, respectively. VAS score was 0 point for all patients. No significant difference could be observed in terms of ankle range of motion, calf circumference measures and dynamometric analysis. Average time for return to daily activities was 11.1 weeks post-surgery. Prerupture activity level was accomplished 14.1 months postoperatively, and all patients were able to perform heel raise test.

Practice Management

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Meaningful use and the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) rules call for doctors to allow patients to view, download and transmit their electronic health record (EHR) data. Some patients are beginning to ask about adding that data to various healthcare apps. National Association for Trusted Exchange CEO Aaron Seib and Co-Chair of HL7's EHR workgroup Gary Dickinson cite issues that may come up when physicians send data to a patient's app. Dickinson notes that although meaningful use and MACRA require physicians to give patients a standard summary via an HL7 standard advising a snapshot summary, including recent laboratory results, medication list and some patient history, some apps will be looking for more specific data than a C-CDA version can provide. It excludes information from other providers the patient may have seen. Another point Dickinson makes is accountability for the summary. Downloading it to an app is “kind of a mixed bag,” which is one reason why so many doctors are nervous about the prospect. Moreover, physicians have issues relying on data they have not collected themselves, which is why they often want to call for a new test on a patient, even though another clinician has already run the same one recently. “We're kind of getting to the point where the data is becoming an avalanche,” Dickinson says. As a result, not all the data collected on the app will be valuable. Seib reports the federal Application Programming Interface task force's recommendations include requiring doctors to supply the same level of privacy assurance when sending to an app as is required for a patient portal.


A recent white paper by athenaHealth highlights five essential building blocks for thriving independent practices:

• Strong focus on financial performance
• Connectivity and clinical integration
• Ability to thrive in a risk-based environment
• A foundation of patient engagement
• Adaptability to change

Maximizing front-desk collections of patients' co-pays and deductibles can be accomplished in two steps. The first step to be performed two days in advance is to review the accounts receivable with the names of scheduled patients. Patients with still-outstanding balances should be given a reminder call or email that includes a reminder about the outstanding balance. These messages ask patients to call, by name, a billing staffer to verify their appointment. When these patients call, they are reminded of the outstanding balance. With larger balances due, and some starting to age, patients are frequently asked to attend to these accounts to keep their appointments. The second step to be carried out one day in advance is to review all accounts of those scheduled. The practice must determine the eligibility of each established patient, as well as whether any deductible is due. If so, this should be noted in the appointment schedule. The amount of the co-payment should also be determined and noted in the schedule.


Vanguard Communications CEO Ron Harman King offers tips physicians and healthcare providers should follow to build an effective website. He says a provider's website should communicate with and serve both current and prospective patients. Five essential site ingredients King identifies include a content management system or website builder, which should preferably be open source. A second element to include is clean, mobile design that provides succinct, text-light content that also is readable on smaller screens. This element requires an experienced web developer. A simple, catchy, easy-to-remember site address is the third critical ingredient, while the fourth is plain conversational language directed to patients instead of to other physicians. The last essential site component is contact and location information that includes clickable phone numbers for smartphone users and Google map locations.

Health Policy and Reimbursement

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The Centers for Medicare and Medicaid Services (CMS) has provoked ire among hospitals. CMS plans to halt payments for hospitals' off-campus facilities as it has for hospital-based outpatient departments as part of its response to calls to remove patient satisfaction on pain management from Medicare's value-based purchasing program. CMS' actuary has calculated that site-neutral payments for ambulatory care, which Congress urged in a 2015 spending bill, would save Medicare about $500 million next year. The American Hospital Association (AHA) released a statement criticizing the agency for declining to include support for hospital outpatient departments. Premier healthcare associations had called on the Obama administration to stop incorporating patients' responses to pain management questions in the Hospital Consumer Assessment of Healthcare Providers and Systems in the value-based purchasing program. "Some stakeholders believe that the linkage of the pain management dimension questions to the Hospital VBP program payment incentives creates pressure on hospital staff to prescribe more opioids," CMS notes. It says eliminating the questions from the survey would "mitigate even the perception that there is financial pressure to overprescribe opioids." Yet the agency still thinks pain control is "an appropriate part of routine patient care that hospitals should manage." CMS proposes to raise the rate for hospital outpatient services by $671 million, and ambulatory surgical centers by $39 million, in 2017 versus 2016. According to AHA Vice President Tom Nickels, the lack of support for outpatient care delivered by hospitals "does not reflect the reality of how hospitals strive to serve the needs of their communities."


The Centers for Medicare and Medicaid Services (CMS) has issued a proposed rule for the 2017 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System, covering payments for outpatient services. CMS estimates a 1.6 percent payment hike in 2017 for hospitals paid under the OPPS, which involves an estimated total payment amount of $63 billion, up $5.1 billion versus 2016. Payments under the ASC system will rise by 1.2 percent for those ASCs that fulfill quality reporting requirements under the Ambulatory Surgical Center Quality Reporting program, which translates into an estimated total payment amount of $4.4 billion, up $214 million compared to 2016.


President Barack Obama has called on Congress to revisit the idea of providing a government-run insurance plan as part of the offerings under the Affordable Care Act. The “public option” was jettisoned from the health law by a handful of conservative Democrats in the Senate in 2009. Every Democrat’s vote was needed to pass the bill in the face of unanimous Republican opposition. But in a “special communication” article published on the website of the Journal of the American Medical Association, the president said a lack of insurance plan competition in some areas may warrant a new look. The president also called on Congress to take more steps to rein in the cost of prescription drugs and make government assistance more generous for those who still cannot afford healthcare coverage, while urging the 19 states that have not yet expanded the Medicaid program under the health law to do it.

Medicine, Drugs and Devices

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The golden age of antibiotics appears to be coming to an end, its demise hastened by a combination of medical, social and economic factors. For decades, these drugs made it easy for doctors to treat infections and injuries. Now, common ailments are regaining the power to kill. “It's a slow catastrophe,” said Army Col. Emil Lesho, director of the Defense Department's Multidrug-Resistant Organism Repository and Surveillance Network. The problem goes beyond treating infections. As bacterial resistance grows, Lesho said, “we're all at risk of losing our access” to medical miracles we've come to take for granted, including joint replacements.


Cost reduction is a contentious subject in perioperative medicine, and a recent study examines the cost minimization and stay length associated with the choice between two short-acting local anesthetics during ambulatory surgery. Thirty mL chloroprocaine 3 percent or 30 mL mepivacaine 1.5 percent were applied as anesthesia to 100 adult patients scheduled for popliteal block after minor ambulatory foot surgery. Onset time (sensory: 4.3 ± 2.4 vs 11.5 ± 3.2 minutes; motor: 7.1 ± 3.7 vs 18.4 ± 4.5 minutes) and block duration (sensory: 105 ± 26 vs 317 ± 46 minutes; motor: 91 ± 25 vs 216 ± 31 minutes) were significantly shorter when chloroprocaine was used. These results also translated to a faster discharge for patients readministered chloroprocaine without negatively affecting the block or patient. Neither anesthetic necessitated unplanned outpatient visits, readmissions or complications at six weeks.


Researchers analyzed medication adherence data from 430 adults with type 2 diabetes at high risk for serious adverse events or death participating in the Southeastern Diabetes Initiative. They found that about half of the cohort was categorized as adherent; however, self-reported adherence was lower than directly observed adherence. Agreement between the two reporting measures was considered “fair.” For both adherence measures, researchers found that higher adherence was associated with lower HbA1c, but the ability of each measure to discriminate between lower and higher blood glucose was weak. The study was published in BMJ Open Diabetes Research & Care.