News From ACFAS

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Controversies. Challenging cases. Complications. Don’t let difficult clinical scenarios get the best of you—mark your calendar now for the new seminar 3 Cs of Deformity Correction, set for November 4–5 in Phoenix.

Experienced faculty will share higher-level management strategies for complex reconstructive cases. Breakout sessions and case presentations combined with interactive discussion show you how to avoid surgical pitfalls and work your way through any complications that may arise before, during or after surgery.

This seminar is worth 14 continuing education contact hours. Registration opens soon—watch This Week @ ACFAS for updates. Learn how to receive proper reimbursement for the expert care you provide in Coding and Billing for the Foot and Ankle Surgeon, October 13–14 in Phoenix. Gain strategies for simplifying your coding and reimbursement processes for:

• multiple-procedure cases when performing forefoot, rearfoot or ankle reconstructive surgery
• open reduction and internal fixation of multiple fractures
• complex arthroscopy cases
• diabetic foot surgery

Faculty will guide you through case-based and interactive procedures as you code real-time patient scenarios. Visit acfas.org/practicemanagement to register today. Now in its 11^th year, the ACFAS Clinical and Scientific Research Grant program continues to support the College’s core goal of advancing evidence-based medicine (EBM) to improve patient care.

Apply for a grant by September 15, 2017 for a chance to have the College help fund your latest research project. This year, the ACFAS Research-EBM Committee would like to see studies on hammertoe implants and ankle implants. For more about the research grant, visit acfas.org or email research@acfas.org.

Foot and Ankle Surgery

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New research compares T1-weighted fat-suppressed spin-echo magnetic resonance (MR) sequences after gadolinium application (T1wGdFS) to short tau inversion recovery (STIR) sequences in patients with acute and chronic foot pain. In 51 patients referred for MRI of the foot and ankle, additional transverse and sagittal T1wGdFS sequences were obtained, and two sets of MR images (standard protocol with STIR or T1wGdFS) were analyzed. Diagnostic accuracy with STIR protocol was 80 percent for reader one, 67 percent for reader two, with contrast-protocol 84 percent, both readers. Significance was found for reader two. Diagnostic confidence for reader one was 1.7 with STIR, 1.3 with contrast-protocol; reader two: 2.1/1.7. Significance was found for reader one. Pain location correlated with STIR sequences in 64 percent and 52 percent, with gadolinium sequences in 70 percent and 71 percent. Researchers conclude that T1-weighted contrast material-enhanced fat-suppressed spin-echo magnetic resonance sequences improve diagnostic accuracy, diagnostic confidence and correlation of MR abnormalities with pain location in MRI of the foot and ankle. However, the additional value is small.


Researchers conducted a study to evaluate the impact of pedal arch status and direct-angiosome revascularization (DAR) on clinical outcomes in patients living with diabetes and foot wounds who undergo endovascular revascularization. Ninety-three patients living with diabetes and foot wounds underwent endovascular revascularization of at least one below-the-knee vessel. Patients were divided into three groups according to the pedal arch status: complete pedal arch, incomplete pedal arch and absent pedal arch. Healing within three months and one-year outcomes in terms of freedom from minor amputation, limb salvage and survival were evaluated on the basis of DAR and pedal arch status. DAR did not affect healing within three months from the procedure, estimated one-year freedom from minor amputation, limb salvage and survival. The study found that DAR is not a predictor of good outcomes in patients living with diabetes who undergo endovascular procedure. Pedal arch patency seems to be a key factor to obtain good outcomes in terms of wound healing and limb salvage.


A new study seeks to assess the incidence of abnormal internal rotation of the talus in the axial plane in patients with varus ankle osteoarthritis and to determine whether this incidence differs from the severity of varus ankle osteoarthritis (moderate versus severe). Researchers retrospectively evaluated weightbearing computed tomography (CT) and plain radiographs of 52 ankles with no abnormalities (control group) and 96 ankles with varus osteoarthritis (varus OA group), which were further stratified into a moderate OA subgroup (50 ankles) and a severe OA subgroup (46 ankles). Researchers used a new radiographic parameter on weightbearing CT, the talus rotation ratio, to assess the rotation of the talus in the axial plane. They defined the normal range of the talus rotation ratio and the abnormal internal rotation of the talus and determined the incidence of abnormal internal rotation of the talus in the varus OA group, moderate OA subgroup and severe OA subgroup. In the varus OA group, the incidence of abnormal internal rotation of the talus was 45 percent (43 ankles), which corresponded to an incidence of 32 percent (16 ankles) in the moderate OA subgroup and 59 percent (27 ankles) in the severe OA subgroup (p=0.013). The research demonstrates that abnormal internal rotation of the talus occurs in patients with varus ankle osteoarthritis and is more frequently noted in severe than in moderate varus ankle osteoarthritis.

Practice Management

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Physicians can use social media to better interact with their patients while improving the care they provide. Social media can be useful for simple administrative tasks, such as posting office hours and appointment availability, and existing patients can link to appointment scheduling software or websites. Furthermore, social messaging apps and telemedicine websites make it possible for patients to receive treatments for a variety of health issues without the need for face-to-face appointments. Medical professionals can provide accurate information through sites like Facebook, Twitter, Instagram and YouTube. Good examples include dermatologist Dr. Sandra Lee in West Los Angeles and Dr. Howard Luks, an orthopaedic surgeon in New York. Lee has a YouTube channel where she showcases various dermatological procedures ranging from blackhead removal to skin cancer surgery in addition to addressing skin health. Luks has a following on multiple social media sites, but most are on Twitter. He uploads videos to YouTube that explain various orthopaedic injuries and offers information about both traditional and innovative treatment options. Social platforms may also help bring new patients into the office. The Internet obviously is not a medium for sharing private patient information, but it is ideal for general Q&A-type conversations.


The changing nature of the medical industry may spur more practices to turn to outsourcing. A 2016 global Deloitte survey found that 59 percent of respondents outsourced to cut costs, and 57 percent did so to focus on core business. Practice leaders should consider whether their team members are addressing responsibilities that benefit the practice the most. For instance, an office manager was impeded in her ability to provide high-quality care and attention to clients and employees because she was devoting several hours a week to growing the practice's online presence. The practice decided to outsource by hiring a social media marketing assistant. Research by Keystone Health Services indicates that outsourcing can potentially save a practice thousands of dollars in yearly benefits and salaries and that outsourcing billing processes improves overall cash flow: "Your practice will see a significant drop in charges and the time it takes to process claims as the outsourcing experts capture and accurately report the information. The result is a steady flow of claims going in and cash coming out." Black Book research indicates that healthcare providers are overwhelmingly turning to third parties to outsource IT needs. Its 2015 survey of 1,030 hospital IT leaders found that nearly 75 percent of health organizations with more than 300 beds have shifted their focus to IT outsourcing for services, such as software development and infrastructure. Among providers with fewer than 300 beds, that percentage is more than 80 percent.

Health Policy and Reimbursement

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A Congressional Budget Office (CBO) analysis estimates that a rollback of the Affordable Care Act (ACA), with no alternative measure to take its place, would leave millions more without health coverage. The population of uninsured persons would swell to 32 million by 2026 from 17 million next year under ACA if key components of former President Barack Obama's signature law are scrubbed, including Medicaid expansion and subsidies for the needy. Removal of a mandate that most Americans get policies or pay a tax, meanwhile, would send premiums up for Americans who do maintain coverage, CBO added. The rise in costs—a 25 percent increase in 2018 compared with ACA and a 50 percent spike by 2020—would stem from healthier people declining coverage, leaving older and sicker people to make up the bulk of the insurance pool.


James Cosgrove, who directs healthcare reviews for the Government Accountability Office, testified on Capitol Hill that federal health officials made more than $16 billion in improper payments to private Medicare Advantage health plans in 2016. In his testimony before the House Ways and Means oversight subcommittee, Cosgrove stressed the need to crack down on billing errors by the insurers. He told committee members that the Medicare Advantage improper payment rate was 10 percent in 2016. Factoring in the overpayments for standard Medicare programs, last year's tally nearly topped $60 billion, or almost double what the U.S. National Institutes of Health spends on medical research annually. "Fundamental changes are necessary," he concluded.


Senate GOP leaders have abandoned their initiative to dismantle and simultaneously replace much of the Affordable Care Act (ACA) after Republican Sens. Mike Lee of Utah and Jerry Moran of Kansas expressed opposition to the latest version of the measure. Senate Majority Leader Mitch McConnell (R-Ky.) says the Senate will instead vote in the coming days on a bill the chamber passed in late 2015 to unravel most of ACA, which was vetoed by former President Barack Obama in January 2016. McConnell says the bill would come as an amendment to the healthcare bill passed by the House in May and would allow for a two-year transition. Many Republican senators have been wary of this strategy because they would not feel comfortable rolling back ACA without being able to tell their constituents what would take its place.


Faced with indecision from Washington, D.C., on the future of healthcare reform, states are trying to hold together individual insurance markets, as some insurers announce plans to pull back or exit insurance exchanges, while others seek major rate increases. States are confronting the possibility that some of their counties will have no options to choose from, with 20 counties in Ohio, four in Indiana and 14 in Nevada at risk of lacking exchange plans next year, according to the Kaiser Family Foundation. Some states are seeking creative solutions. Randy Pate, a deputy administrator at the U.S. Centers for Medicare and Medicaid Services (CMS), said recently that CMS “continues to work with state departments of insurance and issuers to address bare counties, exploring all options available under current law.” State officials, meanwhile, say their hands are tied, as some of the biggest questions bothering insurers are at the federal level.

Legal Briefs

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Dr. Richard Dellerson was once considered one of South Florida's leading experts in emergency medicine. However, Dellerson's reputation was left in shambles following testimony he gave in two malpractice cases. He was popular choice as a witness for the cases, so he participated in many over the years. In 2013, he nearly lost his career after being found of exaggerating his medical credentials and not meeting legal requirements to be an expert witness in a 2009 case. Dellerson warned the trouble began as a result of him failing to confirm his met legal requirements. Experts add that the system of how expert witnesses are sought and used adds to this growing problem surrounding malpractice cases.

Medicine, Drugs and Devices

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According to the U.S. Government Accountability Office (GAO), Medicare spent $6.7 billion on durable medical equipment in 2015. Companies have developed disposable versions of some of these medical devices, such as insulin pumps, that could act as potential substitutes. GAO found that some of these disposable devices could potentially save money or result in better health outcomes compared to the durable versions in some cases, but they are not covered by Medicare. GAO recommends that the U.S. Centers for Medicare and Medicaid Services evaluate the potential costs and savings of using disposable devices as substitutes for durable ones.


A new study conducted by independent research firm Vanson Bourne puts the price tag for disconnected data at $140 billion a year for organizations in the United States and the United Kingdom. Sponsored by data integration software provider SnapLogic, the study is based on a survey of 250 IT decision makers and 250 business users conducted in April and May. Nearly half of respondents (47 percent) said they believe that disconnected data is negatively affecting their organization's ability to innovate, develop new products and services and get them to market quickly. Moreover, their ability to engage, support and meet the needs of customers (46 percent) is also negatively affected. The problem is compounded by aging technology and departments that are overly protective of their own systems and data. More than three quarters (76 percent) of respondents have company data trapped in legacy systems that can not be accessed or linked to cloud services. Also, 44 percent said a lack of collaboration between departments has been a challenge.


Lee Cantrell, who helps run the California Poison Control System, recently sought to discover if expired prescription medicine is still effective or dangerous. Cantrell and Roy Gerona, a University of California, San Francisco researcher, tested 14 different drugs that were decades old. They found that 12 of the 14 drugs were still potent. Their findings could have major impact on guidelines regarding expired drugs and reducing waste in the medical industry. Cantrell says, "Refining our prescription drug dating process could save billions."