News From ACFAS

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As your source for lifelong foot and ankle learning, ACFAS has added trauma to its e-Book series with Trauma of the Foot and Ankle. This third e-Book release guides you through the latest surgical procedures and techniques to help you achieve optimum patient outcomes.

Eighteen chapters written by nearly 40 renowned experts in the field, feature over 400 full-color images and videos. Get the most from your reading with built-in notetaking and bookmarking tools and also earn CME by completing a short self-assessment after each chapter.

Visit acfas.org to purchase the e-Book now. The July seminar is already sold out -- don't miss your opportunity to attend the last 2019 session of the popular Coding & Billing for the Foot and Ankle Surgeon Seminar on September 20-21 in Teaneck, New Jersey.

This interactive course puts you and your fellow attendees in the driver's seat as you work together to code and bill for a week's worth of clinics, surgeries, calls, office procedures and complex cases typically seen in a foot and ankle surgical practice. Instructors will also guide you in how to use modifiers to avoid denials and win appeals.

A special breakout session focused on private and multispecialty practices will close the seminar.

Register yourself and your coding and billing office staff at acfas.org/practicemanagement to secure your spot now! Class of 2019, join ACFAS and take the next important step in your career path! Thanks to the support of our local Regions, first-year podiatric surgical residents receive a complimentary first-year membership to the College. Take advantage of all member benefits, including lowest pricing on conferences, products and services, free for one year (a $124 value).

Enjoy full access to acfas.org, the College’s premier website, and a subscription to the online version of The Journal of Foot & Ankle Surgery (JFAS), your source for the latest surgical techniques and research.

The resident membership year runs from September until October. Join now and get July and August included as a bonus!

Foot and Ankle Surgery

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Researchers sought to evaluate anatomical variations in the lateral ankle and their relationships with pathological conditions of the peroneal tendon on magnetic resonance imaging (MRI) in symptomatic patients. Sixty-nine ankles MRIs of 60 adult patients with symptomatic ankles were included. The presence and sizes of peroneal tubercle and retrotrochlear eminence (RTE), the prevalence of peroneus quartus, os peroneum and boomerang-shaped peroneus brevis (PB) tendon, the shape of the retromalleolar fibular groove and the location of the PB muscle–tendon junction were evaluated. Only boomerang-shaped PB tendons showed a significant relationship with peroneal tendinopathies

MRI and clinical findings had a poor correlation in pathological peroneal conditions and both had low sensitivity in diagnosis. Both clinical and MRI findings have low sensitivity in the diagnosis of peroneal tendinopathies, which are often incidental findings on MRI, the researchers found. They concluded that lateral ankle anatomical variations are common and cannot be attributed to pathological conditions of the peroneal tendon, except for boomerang-shaped PB tendons.


A study compared complication rates of total ankle replacement in two patient cohorts based on body mass index (BMI), with one group having a BMI of about 30 kg/m2 and the other including subjects with a BMI higher than 30 kg/m2. Ninety-seven patients met the inclusion criteria and received total ankle replacement between March 2012 and July 2016. Average BMI was 29.6 kg/m2.

Total complication rates for group one and two were 18.9 percent and 11.4 percent, respectively, with 10 minor and five major complications. Complication rates had no statistical difference between the two groups and all patients underwent at least one concomitant procedure at the time of the index ankle replacement. Total ankle replacement was found to be safe in patients with a BMI greater than 30 kg/m2.


Unstable footwear may enhance training effects to the lower-limb musculature and sensorimotor system during dynamic gym movements. Researchers conducted a study to compare the instability of an unstable shoe with irregular midsole deformations (IM) and a control shoe (CS) during forward and lateral lunges. Seventeen female gym class participants completed two sets of 10 forward and lateral lunges in CS and IM. Ground reaction forces, lower-limb kinematics and ankle muscle activations were recorded. Variables related to initial ground contact, toe-off, descending and ascending lunge phases were compared statistically.

Responses to IM compared to CS were similar across lunge directions. The IM induced instability by increasing the vertical loading rate and variability of frontal ankle motion during descending and ascending phases, in forward and lateral lunges, respectively. At initial ground contact, ankle adjustments enhanced postural stability in IM. Across muscles, there were no activation increases, although results indicate peroneus longus activations increased in IM during the ascending phase. As predicted, IM provided a more demanding training stimulus during lunge exercises and has potential to reduce ankle injuries by training ankle positioning for unpredictable instability, the researchers concluded.

Practice Management

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In its State of Patient Identity Management report, LexisNexis describes the results of a cybersecurity survey with more than 100 respondents from healthcare organizations including hospitals, physician group practices and payers. The survey found 58 percent of healthcare organizations consider their patient portal security above average or superior to other patient portals. In addition, 93 percent of participants said their organization uses only a username and password as the authentication method to log into the patient portal. Moreover, 65 percent said their organization uses multifactor authentication for the portal, with 39 percent using a question and answer prompt, 38 percent using email and 13 percent using device identification.


Negative information tends to prevail over positive information and as a result, people are likely to get more criticism or unsolicited advice than appreciation or positive acknowledgement. The negativity bias impacts work culture and patient care, as personal and medical errors, which are to some degree inevitable, are seen as an occasion for shame rather than an opportunity to learn and adapt. Practice managers can make a positive impact on workplace culture by taking steps to counteract this negativity bias. They can do this by reframing mistakes as learning opportunities, rewarding people for reporting and discussing medical errors and near misses.

When discussing a medical error, focus questions less on personal responsibility (who is responsible) and more on the functional details of an incident (what, how and why it happened). Delay incident report submissions until you've spoken with the person identified in the report, avoiding the problem of reporting systems where people write someone up instead of communicating directly. Supplement learning from errors with acknowledgement of what people have done well, ideally at least eight or nine positives traits.


As out-of-pocket costs and patient liabilities rise amid evolving value-based care requirements, the cost of medical care is shifting from insurers to patients. Medical practices struggling to collect payments from patients can make a variety of adjustments to enable easier, more immediate payment processes for patients. Practices can improve responsiveness by offering a convenient, patient-centered experience, such as an automated insurance eligibility check as soon as the patient makes an appointment to reduce rejections. Patients should be able to fill out intake forms online before their visit or through a patient kiosk prior to the appointment, enabling practices to collect outstanding balances and co-payments for visits.

Providers should also let patients know if the benefit has been exceeded or the deductible has not been met. When it comes to health plans, claims scrubbing, which refers to the practice of proactively identifying and performing corrections for errors in billing codes, can lead to cleaner claims, fewer denials and improved payer communication. To improve upfront collections, practices should work to streamline the payment process, offering patients multiple ways to pay, seamless transactions, payment reminders and online access to their balance. Practices should seek to automate as much of their workflow as possible, reducing opportunities for unexpected developments in denials, ineligibility or larger-than-expected patient responsibility.

Health Policy and Reimbursement

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The U.S. Centers for Medicare & Medicaid Services (CMS) has announced the Merit-based Incentive Payment System (MIPS) has had fewer participants in its second year than in its first though more clinicians who participated received a bonus. The number of participants in the program dropped from 1.06 million to 916,058, while the percentage of clinicians who received a bonus went up from 93.1 percent in 2017 to 97.6 percent in 2018. Some say the high percentage of bonuses show CMS has excluded too many providers, leaving only the high-performing groups.

The CMS excluded more clinicians from MIPS in 2018, raising the minimum threshold of $30,000 in Medicare revenue to $90,000, in response to criticism from small practices that they did not have enough Medicare patients to justify the program’s infrastructure. While MIPS participation decreased, participants in alternative payment models rose from 99,076 in 2017 to 183,306 in 2018, which exclude participants from MIPS and render them eligible for a 5 percent Medicare payment bonus. Some attribute this increase to greater participation in the Medicare Shared Savings Program.


After a panel of appellate judges seemed to favor repealing the 2010 Affordable Care Act (ACA), Senate Republicans are working urgently on a plan to replace the most popular components of the ACA in case the law gets struck down, leaving millions without coverage. Senate Majority Leader Mitch McConnell has abandoned his reluctance to move legislation to replace the ACA before 2020, pledging last week to swiftly protect people with pre-existing medical conditions if a GOP-backed lawsuit successfully overturns the ACA.

Sen. Mitt Romney is leading Republican efforts to preserve the ACA's most popular provisions, namely its protections for people with pre-existing conditions and allowance for young adults to stay on their parents' health insurance until age 26. Romney has said he is unsure when a bill would come together and who would support it. Despite McConnell's assurance the Senate would “act quickly on a bipartisan basis,” Democrats are unlikely to support any Republican plan to address pre-existing conditions, saying the GOP can't “have it both ways” in supporting the lawsuit and trying to undo its effects.


According to the 2019 Health Insurance Index Report released July 16 by eHealth, Affordable Care Act (ACA) participants who did not qualify for subsidies, who accounted for 64 percent of all enrollment applicants in the fourth quarter last year, faced record-high premiums. Families of four paid an average monthly insurance premium of $1,403, while two-person families paid over $1,000 and individuals paid $448 on average. Premiums have risen 65 percent for individuals and 73 percent for families since the ACA's first open enrollment period in 2014. While premiums hit record milestones, deductibles dropped dramatically for the first time since 2014, decreasing by 6 percent for individuals and 8 percent for families.

Medicine, Drugs and Devices

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According to newly-disclosed data from the U.S. Drug Enforcement Agency (DEA), U.S. drug companies distributed 76 billion oxycodone and hydrocodone pain pills from 2006 through 2012. The information comes from a DEA database known as the Automation of Reports and Consolidated Order System (ARCOS), which uses company-provided data to track the path of every pain pill sold in the United States from manufacturing to distribution. According to ARCOS, the volume of prescription opioids produced in the United States increased by 51 percent from 2006 to 2012, with three companies manufacturing 88 percent of these pills and six companies distributing 75 percent of them.

ARCOS shows companies ignored persistent red flags that their drugs were being sold illegally and diverted to black markets. Beginning in 2005, the DEA began issuing letters to drug distributors and manufacturers warning them they were required to report suspicious orders of painkillers and halt sales until the red flags could be resolved. Despite these warnings, DEA officials said the companies continued to ship millions of pills in suspicious circumstances. Though the DEA brought a series of civil enforcement cases against the largest distributors, ARCOS data shows that even as the companies paid fines and promised to do a better job of stopping suspicious orders, they continued to manufacture and dispense large amounts of pills. In addition, journalists successfully lobbied for access to filings that revealed thousands of ongoing lawsuits in a Cleveland federal court, in which cities, towns and counties are suing the companies they say conspired to flood the nation with opioids.


A new University of Michigan study published in the American Journal of Critical Care finds 25 percent of hospital infections are caused by indwelling devices like catheters. The study interviewed a group of nurses, physician assistants, nurse practitioners and physicians about problems monitoring and communicating among their teams about indwelling catheters. All respondents said poor communication was a main factor in delayed catheter removal, which can cause infection or unnecessary catheter use. Efforts to reduce catheter use and misuse haven't succeeded as much as healthcare workers would like, the study finds, largely due to poor physician-nurse communication. Catheters are hidden under blankets, so physicians don't automatically know who's using one - especially if a nurse isn't there to point it out. Researchers say the findings underscore the fact that communication issues among healthcare workers can lead even routine care to cause problems for patients.


Following the March 2019 closure of a large medical device sterilization facility, the U.S. Food and Drug Administration (FDA) has announced two Innovation Challenges to encourage the development of new approaches to device sterilization. The first aims to identify new sterilization methods and technologies, while the second works to reduce ethylene oxide emissions to as close to zero as possible. The FDA invites participation in this challenge from sterilization companies, medical device companies, technology manufacturers, academic and research institutions, healthcare facilities, professional societies and non-profits. The submission deadline is October 15 and the FDA will announce selected applications in December 2019.