News From ACFAS

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Don't let the chance to share your latest research with your peers pass you by--all manuscript entries for the annual manuscript competition at ACFAS 2020 in San Antonio are due by August 15 2019.

Manuscript submissions are blinded, reviewed and judged on established criteria. Winners divide $10,000 in prize money supported in part by a grant from the Podiatry Foundation of Pittsburgh.

For submission criteria and guidelines, visit acfas.org.

If so, ACFAS is looking for speakers to join its Practice Management faculty.

If you are a dynamic speaker with advance knowledge in:

• coding and billing practices,
• insurance denials,
• medical documentation,
• ICD-10,
• Medicare audits,
• surgical coding,
• practice management,

complete a Practice Management Faculty Application and send it to Melissa Matusek, director of Marketing and Communications. Stay ahead of the latest research in foot and ankle surgery without having to go on a scavenger hunt to find it -- take advantage of ACFAS' monthly Scientific Literature Reviews. These reviews are short, digestible summaries of studies from hundreds of medical specialty journals covering the latest developments in foot and ankle surgery.

Available at acfas.org/SLR, the latest articles for August are now ready for you. Highlight topics include: a peroneal nerve study, Anterior Talofibular Ligament repair, comorbidities and surgical site infection and many more!

Foot and Ankle Surgery

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The plantar loading variables between habitual rearfoot strike (RFS) and non-rearfoot strike (NRFS) during running is the focus of a new study. Researchers used in-shoe pressure sensors to measure plantar loading of 78 healthy males (41 RFS, 37 NRFS). Force and pressure parameters were much higher in the rearfoot and midfoot regions during RFS running and relatively greater in forefoot region during NRFS running. However, compared with NRFS running, the contact area, maximum force and force-time-integrals during RFS running on total foot were 21.44 percent, 13.99 percent and 21.27 percent higher, respectively.

Total foot peak pressure and pressure-time-integral between two FSPs were similar. Higher loads in the rearfoot region may transmit to the knee joint and result in patellofemoral joint injuries. NRFS runners' higher loads in forefoot seem to be related to metatarsal stress fractures and compensatory damage to the Achilles tendon. As a result, runners should choose proper FSPs according to their unique physical conditions.


In this systematic literature review, the author evaluated present knowledge about peroneal tendon injuries at the lateral calcaneal wall, which are predominantly associated with peroneal tubercle enlargement. Across 14 published articles, there is available information on 25 patients (26 cases), all of whom were treated surgically, with excellent or good reported results. Enlarged peroneal tubercles were resected, and groove deepening and inferior peroneal retinaculum reconstruction addressed distal peroneus longus tendon dislocations.

Until now, only three reports presented five patients with dislocation of the peroneus longus tendon combined with inferior peroneal retinaculum lesions, in which cases the peroneal tubercle as not enlarged. In rare cases, recurrent dislocations can cause lesions of the peroneus longus tendon at the peroneal tubercle, which can be addressed surgically. In cases without tendon dislocation, the enlarged peroneal tubercles are removed or shaped, whereas dislocations in normal shaped peroneal tubercles require groove deepening and inferior peroneal retinaculum reconstruction.


New research seeks to correlate sesamoid malalignment with hallux valgus (HV) severity and findings of internal joint derangement. Researchers analyzed a series of 56 consecutive patients who had X-rays and MRI performed on the same foot within three months of each other. They assessed and correlated multiple measures of sesamoid displacement (SD) on X-rays and MRI and the sesamoid rotation angle (SRA) on MRI with hallux valgus angle (HVA) and various qualitative features at the hallux-sesamoid complex (HSC), including cartilage, plantar plate and collateral ligament abnormalities.

The researchers found excellent Inter reader reliability (IRR) for SRA on MR, but poor IRR for lateral sesamoid displacement (LDS) and tibial sesamoid position (TSP) scales on both modalities. Good IRR was also seen for morphologic abnormalities of HSC; the absolute value of the SRA on MR positively correlated with HVA; LDS and TSP on both modalities lacked a significant correlation with HVA; and no correlation was found between any measure of SD or rotation with HSC morphologic changes. Researchers conclude that among different measures of sesamoid malalignment, SRA measured on MRI can be used to judge the severity of HV. However, it does not correlate with qualitative morphologic abnormalities of the HSC.

Practice Management

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Thanks to wearable health devices and smartphone apps, today's patients are collecting a massive amount of health-related data. While some have overstated the potential of the technology, multiple use cases demonstrate that it has real potential to improve healthcare. For example, one study involved a pilot program using 24/7 patient monitoring through technology to improve the health of employees with three or more chronic health conditions. The program helped 50 percent of participants get their blood pressure under control within months and saved each employee $250 per month.

Beyond helping patients with chronic diseases manage their day-to-day care, wearable data can also provide doctors an opportunity to prevent these diseases from developing by spotting risk factors and warning signs early on. Despite its vast potential to improve healthcare, the sheer quantity of biometric data produced presents a challenge in itself. Many providers already struggle with cognitive overload from their electronic health records, and if biometric data is simply dumped into these systems unprocessed, doctors are likely to ignore it.

To add value for physicians and patients, the data will need to be presented by a tool that is advanced enough to analyze and report on trends in the data. Providers can help curate what information comes in from patients by working with them to understand what kind of data they can or do collect, what they hope to do with it and what kinds of data are most useful for their specific medical needs.


The growing popularity of smart assistants raises new questions about the confidentiality and integrity of protected health information (PHI). In April, Amazon announced the rollout of new HIPAA compliant skills in several hospitals, but the HIPAA Journal cautions that recordings from these allegedly compliant devices can be used by a select group of healthcare organizations to communicate PHI without violating the HIPAA Privacy Rule. In July, a class action lawsuit was filed alleging that Google violated the Illinois Biometric Information Privacy Act (IBIPA) by sharing audio recorded from their Google Assistant-enabled devices with third parties.

Before utilizing a smart assistant, doctors should fully understand the privacy statements and conduct a thorough risk analysis, understanding that recorded items can be subpoenaed in a legal proceeding and making sure patients give consent to be recorded. Physicians and providers must ascertain whether the smart assistant meets the Security Rule’s technical, administrative and physical safeguards and ensure that the data it gathers is not being shared with third parties.


The U.S. Centers for Medicaid and Medicare Services (CMS) announced a pilot program to give clinicians access to claims data for their Medicare patients. As part of this “Data at the Point of Care” pilot, which will begin in fall 2019, CMS will let participating fee-for-service providers request Medicare claims data for their patients. The pilot aims to overcome silos in the healthcare system, giving providers a more complete understanding of their patients' medical history before making care decisions, potentially avoiding costly duplicate tests or treatments.

CMS Director Seema Verma believes that providers who participate in value-based models will be particularly interested in the pilot, letting them better analyze their patient population. Participating providers must establish a way to access the Medicare claims data from within clinician workflows, which will require collaboration with electronic health record system vendors to connect the appropriate system to the Data at the Point of Care API.

Health Policy and Reimbursement

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At a recent meeting of the National Governors Association, U.S. governors discussed what to do if an appeals court upholds a ruling that would overturn the Affordable Care Act (ACA). Several states have passed legislation to protect ACA coverages in case the law is overturned. Earlier this year, Nevada passed a law forbidding health insurers from denying coverage to patients due to pre-existing conditions. New Mexico has passed laws to enshrine certain provisions of the ACA, including guarantees to coverage for patients with pre-existing conditions and access to contraception without cost-sharing.

California Governor Gavin Newsom said that the state's decision to tax people without health insurance represents a first step in a contingency plan if the ACA is struck down. The state is also looking at Massachusetts' state-run health care program and considering whether a single-payer model would work if the ACA is overturned. The Republican governors were more reserved, with Utah Gov. Gary Herbert saying that striking down the ACA would give Congress a perfect opportunity to craft a better program with bipartisan support. Both he and Arizona Gov. Doug Ducey said that their states will not start working on a contingency plan for people who would lose coverage until the appeals court rules.


The U.S. Centers for Medicare and Medicaid Services (CMS) has announced several draft rules to change how it pays clinicians for many office visits, which are in line with recommendations and research findings provided by the American Medical Association (AMA). This includes updates to its proposed physician fee schedule for 2020, through which CMS is looking to modernize the approach used to pay for evaluation and management (E/M) services. The changes for CPT also change the medical decision-making process for the codes, requiring performance of history and exam only as medically appropriate and allows clinicians to choose the E/M visit level based on medical decision-making or time involved.

CMS also said it intends to incorporate the values recommended by the AMA's Relative Value Scale Update Committee (RUC), which would increase payment for office/outpatient E/M visits. CMS says that increasing the value of these E/M represents an investment in “the critical thinking required to evaluate a patient, which will help improve outcomes.” In addition to these pay process adjustments, CMS has put forth separate proposals that press for more transparency about negotiated hospital prices, as well as the creation of incentives for dialysis centers to develop new technologies.


Hospital discharges averaged 12.8 per 100 people in the three years before implementation of Medicare and Medicaid and 12.7 per 100 people in the three years afterward, and dropped from 9.4 per 100 people in the three years before implementation of the Patient Protection and Affordable Care Act to 9.0 per 100 people in the three years afterward, according to a new study in the Annals of Internal Medicine. The implementation of Medicare and Medicaid and the Affordable Care Act are the two biggest expansions of health benefits in U.S. history. “Contrary to expectations, overall hospitalizations didn't rise after both expansions - suggesting that universal coverage expansions like Medicare for All also won't cause a surge in hospitalizations,” said Dr. Adam Gaffney, lead author of the study and president of Physicians for a National Health Program, an organization that advocates for Medicare for All.

Medicine, Drugs and Devices

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Diabetes patients are increasingly testing their blood sugar with disposable electronic skin patches and phones, rather than pricking their fingers. Many diabetics currently wear coin-sized patches on their arms or stomachs that assess glucose levels automatically, then send this information to the patient's smartphone or a wearable insulin pump. The skin patches insert a small needle into the skin to detect blood sugar fluctuations and transmit readings wirelessly.

Use of digital blood-glucose monitors has risen due to upgrades in the technology's accuracy and as more health plans cover the devices. Certain monitors sound alarms and retain long-term data that patients can share with doctors.


The Trump administration has announced that it would start forcing hospitals to publicly disclose the discounted prices they negotiate with insurance companies. The plan, issued as a proposed federal rule, is mean to help patients shop for better deals on a range of medical services. The industry is likely to challenge the rule in court before it could take effect. After failing to repeal and replace the Affordable Care Act, the Trump administration has shifted its focus to medical and drug prices, and the announcement is part of a broader initiative to make information on healthcare pricing and quality more transparent. “The reality is in every other part of our economy you can get pricing information, but somehow in healthcare, which is arguably some of the most dollars that we spend, you can’t,” said Seema Verma, the administrator for the Centers for Medicare and Medicaid Services, announcing the proposed rule. “We’re trying to change the paradigm.”


The U.S. Department of Health and Human Services (HHS) outlined two potential initiatives that would create “pathways” to importing Canadian drugs to the United States. In one initiative, the U.S. Food and Drug Administration (FDA) and HHS would set up pilot projects from states or wholesalers, outlining how to import certain Canadian drugs that meet the FDA's standards. In a separate initiative, the FDA would prepare safety guidelines for drug manufacturers who want to import drugs they sell abroad to the U.S. market. Manufacturers would use a new National Drug Code that could allow them to price drugs lower than what their current distribution contracts require.