News From ACFAS

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Register today for both Comprehensive Reconstruction of the Foot and Ankle and All About the Ankle, the newest additions to our Surgical Skills series, and get the inside edge on complex revisions and all manner of ankle procedures.

Each course provides generous cadaveric lab time, one-on-one instruction with respected leaders in the profession and a fireside chat during which you can share radiographs of your most challenging case with your colleagues. Also gain treatment strategies and practical, streamlined techniques that lead to the best patient outcomes and help you avoid complications.

Space for these courses is limited, and spots are filling quickly. Visit acfas.org/skills for dates, details and to register. Exhibit at our 75^th Anniversary Scientific Conference in Las Vegas next year and connect with an estimated 1,800+ attendees who want to learn more about your product or service.

The Exhibit Hall will cover more than 100,000 square feet in the Mirage Convention Center and will offer unopposed viewing time to help you network with attendees and forge new client relationships. For maximum exposure, you can also sponsor an event or educational grant, advertise in our digital or print media or feature your company logo on conference products.

Reserve your booth at acfas.org/asc or refer to the Exhibitor Prospectus you received in the mail. Step inside the minds of some of the best in the profession in Arthroscopy of the Foot and Ankle e-Book. Get full access to the insights of authors who are respected arthroscopists in the field in this 16-chapter new release from ACFAS. Immerse yourself in more than 40 videos of real cases to guide you through the latest arthroscopic procedures and techniques, and after each chapter, test your knowledge in self-assessments to help you earn CME.

Visit acfas.org to purchase the e-Book and stay tuned for updates on other e-Books in production.

Legal Briefs

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On June 16, the U.S. Supreme Court issued a unanimous decision in Universal Health Services, Inc. v. United States ex rel. Escobar. The high court upheld what is termed the "implied certification" theory of liability under the False Claims Act (FCA), while adopting a more rigorous materiality standard for determining liability in such cases. Historically, the government and plaintiffs, without any authority, have argued that the federal FCA can be violated if a physician or other provider or supplier submits a claim when the provider did not meet all compliance standards associated with that claim. However, some circuit courts of appeals across the country have said there should not be an implied certification theory. The new demanding "materiality" standard will offer physicians and providers an additional defense in FCA cases going forward. The number of FCA cases based on the implied certification theory may not necessarily increase after Escobar. It is also possible Congress will respond with changes to the statute to wipe out the new "materiality" test. This would likely result in a wave of new FCA lawsuits.

Foot and Ankle Surgery

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Popliteal sciatic nerve catheters (PSNCs) are associated with a high frequency of displacement. New research aims to estimate the frequency of catheter displacement using magnetic resonance imaging (MRI) for patients with PSNCs after major foot and ankle surgery. Forty patients were randomly allocated to catheter insertion either with a short-axis in-plane (SAX-IP) approach perpendicular to the nerve or with a short-axis out-of-plane (SAX-OOP) approach parallel to the nerve. All patients had correct primary catheter placement. The frequency of displacement 48 hours after insertion of the PSNC was 40 percent when inserted perpendicular to the nerve compared to 10 percent parallel to the nerve. The relative risk of displacement was four times larger in the SAX-IP group compared to the SAX-OOP group. Morphine consumption was 150 percent greater in the SAX-IP group compared with the SAX-OOP group. The researchers conclude that PSNCs for major foot and ankle surgery inserted with ultrasound guidance parallel to the sciatic nerve have a significantly lower frequency of displacement compared with those inserted perpendicular to the nerve.


Tibio-talo-calcaneal (TTC) arthrodesis is a treatment for patients with severe degeneration of the ankle joint, consisting of an intramedullary (IM) nail used to fuse the calcaneus, talus and tibia bones. However, poor bone quality can present complications due to nonunion. A new IM nail containing a nickel titanium (NiTi) rod uses its pseudoelastic properties to apply active compression across the fusion site. A study was performed to determine the effect of the new device on bone quality change and to gather load-sharing properties during gait loading. Bone and device computational models were used to simulate the mechanical response of the NiTi rod. During the highest magnitude loading of gait, the bone took more than 50% higher load than the load taken by the nail. Results seem to indicate a prevention of stress shielding by allowing an even distribution of load between bone and nail. The model suggests that a 10 percent decrease in bone modulus results in 3.4 percent higher stress in the nail and a 0.5 percent decrease in stress on the bone.


A new study examines the influence of negative-pressure wound therapy on tissue oxygenation in diabetic feet. Researchers measured transcutaneous partial oxygen pressures to determine tissue oxygenation levels beneath negative-pressure wound therapy dressings on 21 feet of 21 diabetic foot ulcer patients. A transcutaneous partial oxygen pressure sensor was fixed at the tarsometatarsal area of contralateral unwounded feet. A suction pressure of -125 mm Hg was applied until transcutaneous partial oxygen pressure reached a steady state. The transcutaneous partial oxygen pressure values for diabetic feet were measured before, during and after negative-pressure wound therapy. The researchers found transcutaneous partial oxygen pressure levels decreased significantly after applying negative-pressure wound therapy in all patients. Mean transcutaneous partial oxygen pressure values before, during and after therapy were 44.6 (SD, 15.2), 6.0 (SD, 7.1) and 40.3 (SD, 16.4) mm Hg (P < .01), respectively. The results show that negative-pressure wound therapy significantly reduces tissue oxygenation levels in diabetic feet.

Practice Management

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Management guidelines are vital to the smooth operation of a medical practice and should be crafted carefully to ensure compliance and efficiency. First, clearly define the practice’s guiding principles to declare the values of the practice, including time, attitude, communication, appearance and disharmony. Create actionable expectations, follow them consistently and invite staff to contribute when crafting policies. Staff involvement will likely bring a deeper sense of ownership and respect to the practice and can provide a variety of unique perspectives when setting guidelines. Practices should also determine protocols for handling situations where the guidelines have been broken or disrespected and refer to a written procedure during conflict. Management guidelines must be reassessed annually to ensure that the manual is timely and relevant to any changes occurring within the practice. Regardless of policy, expectations should be clear, accessible to staff and observed consistently.


Once implemented, the Medicare Access and CHIP Reauthorization Act (MACRA) will emphasize reimbursement based on value to patients and electronic health record (EHR) metrics focused on performance instead of process. However, value-based care is partly reliant on enforcement of standardized, evidence-informed protocols, which could limit physician autonomy. Although standardized evidence-informed clinical guidelines can improve outcomes for many patients, patients presenting atypical signs of common disorders may require customized evidence-based care. Meaningful use rules have cost physician practices an estimated $15 billion annually, with 44 percent of emergency department shift time for physicians consumed by data entry. Under MACRA, MU becomes Advancing Care Information (ACI), but it is unclear if ACI rules will address these documentation problems. Solo physicians and smaller group practices lacking costly data reporting capabilities are concerned about the Merit-based Incentive Payment System, which distributes reimbursement based on physician performance. Physicians are also concerned that the additional rules and reporting requirements under MACRA will lead to higher rates of physician burnout and dissatisfaction. Premature physician retirement due to burnout combined with practices opting out of Medicare could result in decreased access to medical care in some underserved areas. Complex and time-consuming documentation rules can also cause an increased risk of medical errors, as time is taken away from patient interaction and decision making. As MACRA rules are finalized, physicians should emphasize the preservation of their autonomy, a streamlined data capture system and a focus on patient-centered quality metrics.


Video can be a valuable marketing tool for practices to engage and attract potential and existing patients, and digital content can reach more viewers than advertising on broadcast or cable TV. Video content can more quickly and effectively communicate messages to consumers than text and can help endear a practice to the community. When launching a video strategy, practices should first make a video introducing their providers, expressing practice strengths and showing the facility. Videos that promote procedures and services can answer common patient concerns while emphasizing the benefits and the practice’s expertise. Likewise, brief educational videos about relevant topics of interest, such as postprocedure care, can be valuable resources for patients. Content should typically be between one to five minutes and focused on one primary objective. In some cases, patient testimonials or physician anecdotes can evoke meaningful emotion and inspiration, but providers should be mindful of the Health Insurance Portability and Accountability Act and obtain the appropriate signed releases. If using YouTube, include keywords in the video title to help viewers find the channel and organize videos according to topic or theme. When new videos are released, a practice’s social media, website and email newsletters can promote the content and encourage consumer engagement.

Health Policy and Reimbursement

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The majority of hospitals still have significant work to do in preparation for submitting electronic clinical quality measures by the February 2017 deadline, according to a Joint Commission survey. Thirty-seven percent of hospitals have much to do before they can feel comfortable submitting in accordance with the Hospital Inpatient Quality Reporting Program, and 41 percent have some preparation needed to meet the eCQM deadline. Only 18 percent of hospitals are on track and working toward readiness, and less than two percent would be comfortable submitting eCQMs tomorrow. Although 86 percent plan to meet the February 2017 deadline, others may request an extraordinary circumstances waiver or opt out of submitting eCQMs and risk losing a 2018 incentive payment. Of those opting not to submit, about 29 percent believe the risk is financially worth it for their institutions. The majority of respondents remain confident that a full report would be feasible by February, and 64 percent believe they have the skills necessary to implement eCQMs. About 21 percent are not able to purchase the technology needed for eCQM reporting. Only 18 percent of respondents believe eCQMs reflect accurately upon a hospital's quality; others would not be likely to use this method to measure quality if it was not mandatory.


On October 1, new International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) codes will go into effect. New codes have been added for bunions (M21.61-) and bunionettes (M21.62-). In addition, new codes for periprosthetic fracture around internal prosthetics were added to specify joint and laterality, including type of encounter (M97-). Also added were new codes to define laterality and encounter type for other fractures of the foot (S92.81-), as well as new codes and subcategories for Salter-Harris Type physeal fractures of the ankle or foot specified by bone, type of fracture and encounter type (S99.0-, S99.1, S99.2-).


The Office of the National Coordinator for Health IT (ONC) has released a scorecard to help providers and developers identify and resolve issues involving Consolidated Clinical Document Architecture (C-CDA) documents. ONC’s scorecard reflects whether a C-CDA document meets the requirements of the 2015 Edition Health IT Certification for Transitions of Care. A grade is also given based on a set of interoperability standards set by Health Level Seven. Providers can check their implementations and test system configurations to discover bugs. C-CDA was produced to create a set of interoperable CDA templates, which provides common architecture and language for the creation of electronic clinical documents. The scorecard does not retain C-CDA files submitted by providers, and files are deleted from the server after processing; however, ONC recommends that providers refrain from including protected health information or personally identifiable information in file submissions.

Medicine, Drugs and Devices

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A joint study conducted by two Swiss universities examined the practical application of microrobots during complicated operations. Researchers modeled the microrobots after the physical attributes of bacterium and remotely steered the bio-inspired technology using electromagnetic fields. When heated, the robot can shift in size and shape. Studies have yet to show definitively if the microrobots can successfully maneuver inside the human body, but the researchers believe nanotechnology will aid doctors during dangerous operations and more efficiently deliver drugs to the body's cells. The study was published in the journal Nature Communications.


Surging costs for Medicare’s catastrophic prescription coverage shells out billions of dollars for drugmakers at taxpayer expense, according to Medicare’s Office of the Actuary. The cost of catastrophic coverage jumped by 85 percent, from $27.7 billion in 2013 to $51.3 billion in 2015. Originally designed to protect patients taking many different high-cost medicines, senior beneficiaries pay 5 percent for prescriptions after spending $4,850 of their own money. This threshold is crossed quickly, however, as some drugs are priced at $1,000 per pill. Medicare pays 80 percent of the cost above the catastrophic threshold, leaving taxpayers a steep bill for the most expensive patients. Catastrophic coverage costs account for 37 percent of Medicare drug spending, but only 9 percent of beneficiaries reach the threshold. Likely due to rising drug costs, average premiums for five of the top drug plans rose by more than 15 percent. "The incentive is to price it as high as they can," says Jim Yocum, senior vice president of Connecture Inc. "So you max out your pricing and most of that risk is covered by the federal government."