News From ACFAS

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What does a team approach to diabetic limb salvage look like? Find out in this month’s podcast, “Team Approach to Diabetic Limb Salvage,” available now in the ACFAS e-Learning Portal.

Hear a panel of DPMs and a registered dietitian-nutritionist/certified diabetes educator share their advice for building a care team that ensures the best outcomes for patients undergoing diabetic limb salvage surgery. Learn the importance of:

• Infection management and glucose control in patients before and after surgery
• Comprehensive nursing care throughout treatment
• Inpatient and outpatient education
• Working with diabetes educators to help patients recover and adjust after surgery

Visit acfas.org/e-Learning ACFAS’ complete podcast library and for new monthly releases on other hot topics in foot and ankle surgery. Set the course for the future of podiatric medicine by publishing your original research study in The Journal of Foot and Ankle Surgery (JFAS).

Reach a targeted audience of foot and ankle surgeons, podiatrists, orthopaedic surgeons and other specialists who depend on JFAS for the latest on new surgical techniques and ways to improve patient care. JFAS also allows you to publish your study as an Open Access article to give your research global exposure.

See the “For Authors” section on the redesigned jfas.org for more on how to submit your article for consideration. Class of 2018, get your first year of ACFAS membership for free! Thanks to the local ACFAS Regions’ support, your dues for the first year are waived. As an ACFAS member, you will receive:

• a subscription to The Journal of Foot & Ankle Surgery (JFAS)
• access to the Journal through the JFAS iPad app
• discounted resident member pricing on conferences, products and services
• member access to acfas.org

Don’t delay—apply for membership now at acfas.org.

Foot and Ankle Surgery

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The purpose of this study was to determine whether the quality of preoperative closed reduction in patients with operative ankle fractures affects postoperative wound complications. Researchers performed a retrospective analysis of patients with isolated, closed operative ankle fractures treated at two Level I Trauma Centers who had an initial closed reduction performed on presentation. Patient data was collected and a novel grading system to assess reduction quality was evaluated for inter- and intraobserver agreement.

Of 161 patients, 17 percent sustained a postoperative wound complication. The researchers found no statistically significant association between wound complications and quality of preoperative closed reduction nor with multiple reduction attempts. However, patients with poor initial reductions had a decreased mean time to surgery (1.4 ± 2.9 days versus 4.7 ± 6.3 days), which may have been protective. Interclass correlation coefficients for inter- and intrarater reliability of the classification schema was 0.942 and 0.922, respectively, demonstrating excellent agreement.

The researchers discovered no association between preoperative closed reduction quality and incidence of postsurgical wound complications in patients with operative ankle fractures. Although initial ankle reduction is still recommended, multiple attempts to achieve a perfect reduction are likely unnecessary.


Minimally invasive dorsal cheilectomy (MIDC) for hallus rigidus is gaining in popularity. The optimal position for the stab incision for MIDC is dorsomedial to allow an ergonomic sweeping movement of the burr, potentially putting the dorsomedial cutaneous nerve (DMCN) to the hallux at risk. The researchers aimed to quantify the risk of using this minimally invasive technique with a cadaveric study.

A total of 13 fresh-frozen cadaveric specimens amputated below the knee were obtained for this study. After the procedure, the specimens were dissected, and structures were inspected for damage. The DMCN to the hallux was cut completely in two specimens. All the extensor hallucis longus tendons were intact, although in one specimen, the tendon showed some fraying on the underside of the tendon. The average distance of the stab incision from the first metatarsophalangeal (MTP) joint was 17.7 mm. The relationship of the DMCN to the stab incision was variable. The average distance of the DMCN to the incision was 3.8 mm. The danger zone for damaging the DMCN was at one third the length of the first metatarsal proximal to the first MTP joint.

The researchers concluded that the DMCN has been well studied by several authors and has a variable course. This nerve was damaged in 15 percent of specimens following MIDC. The researchers believe patients should be made aware of this risk when considering surgery. A carefully made working capsular pocket for the burr and marking this nerve before making the incision if palpable could mitigate this risk.


This randomized controlled trial sought to compare the surgical outcomes of two different ankle stabilization techniques: the modified Broström procedure with calcaneofibular ligament (CFL) or no CFL repair anterior talofibular ligament (ATFL) only.

A total of 43 patients were followed up with prospectively for at least two years. Functional outcomes were assessed using the Karlsson-Peterson and Tegner activity level scoring systems. Anterior talar translation (ATT), talar tilt angle (TTA) and degrees of displacement of the calcaneus against the talus on stress radiographs were measured. All parameters were compared between the two groups. Multiple regression analysis setting the postoperative Karlsson-Peterson score as the dependent variable was performed to determine the significant variable.

There were no significant differences between the two groups in functional (Karlsson-Peterson and Tegner activity level) scores at the last follow-up. There were no significant differences between the two groups in the ATT, TTA, their differences compared with the contralateral ankles and degrees of displacement of the calcaneus against the talus at the last follow-up. Osteochondral lesion of the talus rather than CFL repair was the significant variable related to functional outcome.

The researchers concluded that the modified Broström procedure with additional CFL repair did not result in a significant advantage in any measured outcome at three years.

Practice Management

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U.S. Centers for Medicare and Medicaid Services (CMS) Administrator Seema Verma wants digital health information to replace the use of fax machines in doctor offices to send patient data. At a recent interoperability forum, Verma said CMS and the U.S. Office of the National Coordinator for Health Information Technology (ONC) are teaming up to achieve a health ecosystem that sees the free flow of information between patient, provider and payer. Related to this, CMS is seeking Blue Button 2.0 app developers interested in building consumer-friendly applications for Medicare beneficiaries to connect their claims data to the applications, services and research programs they trust. "If I could challenge developers on a mission, it's to help make doctors' offices a fax-free zone by 2020," she said.

Verma also stressed her commitment to breaking down barriers to interoperability. Health information technology remains far behind all major industries, she noted, and instead of making work easier for physician, electronic health records are contributing to their burnout. Meanwhile, patients are often prevented from sharing their data with another provider because systems are afraid the patient will be poached. "We can keep data secure, while making it available to patients," she said. To avoid payment reductions, physicians and hospitals will need to give patients electronic access to their health records. Verma said she has also urged insurers to release their claims data so that health data is no longer locked in siloed systems.


Alerting doctors about patients' deaths from opioid overdose helps reduce their prescribing of these drugs, according to a new study published in the journal Science. In an attempt to get physicians to rethink their prescribing habits, the San Diego County medical examiner's office sent letters to doctors informing them of a patient's death related to prescription drug overdose and offering prescribing tips proven to help lower overdose death rates. Through this approach, researchers aimed to get physicians—who tend to view the opioid crisis as stemming from other doctors' poor management—to understand how their own decisions may contribute in small ways to a national epidemic and then give them tools to guide a change in behavior.

Dated January 27, 2017, the letter was sent to 388 doctors who had prescribed at least one of several drugs with known risks to a patient within a year of that person's overdose death. Compared with physicians who did not receive a letter, those who did reduced their prescribing of opioid medications by nearly 10 percent over the three-month study period. Doctors who got the "courtesy communication" started 7 percent fewer patients on a regimen of prescription opioids. They were also between 3 percent and 4.5 percent less likely to write prescriptions for the highest doses of opioids, which are most often implicated in fatal overdoses.

The researchers acknowledged that although the shift may seem marginal, such an initiative could help encourage doctors to adopt safer prescribing practices.


In a new approach to practice management, Atlanta-based HIPnation has separated the concept of healthcare from health insurance. By removing insurance companies from the doctor-patient equation, it proposes to create a deeper connection between providers and patients.

The physician practice management startup says its model could reduce cost and enhance patient care, yet it also moves beyond concierge medicine. Along with owning or partnering with primary care practices, the company has established a local network of specialists, as well as laboratory, imaging and pharmacy services. The HIPnation model limits a physician's case load to 700 patients, compared to more than 2,000. In addition, patients pay a $100 monthly membership fee to select and access one of the company's primary care physicians. No insurance is accepted. "We are not insurance and not trying to be," says HIPnation CEO Will Hall. "We provide healthcare services, and we put insurance in its proper place for high-dollar, low-frequency events."

Separating the connection between providers and health insurance puts the responsibility on the patient to ensure they have the right type of coverage, so experts warn that patients should understand coverage limits. The HIPnation concept could appeal to physicians who currently operate independent practices, as well as those who previously sold their operation to a health system. HIPnation says its approach reduces costs to the healthcare system, increases efficiency and offers price transparency, among other benefits.

Health Policy and Reimbursement

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U.S. Department of Health and Human Services (HHS) Secretary Alex Azar has indicated he will focus on certificate-of-need and scope of practice regulations and on overhauling Medicaid's drug rebate guidelines. In an address for the annual American Legislative Exchange Council meeting, Azar called these certificate-of-need rules a "significant barrier to new competition and lower-cost market disruptors." Azar also presented new guidance intended to deter manufacturer gaming of the Medicaid drug rebate program. The Trump administration will prevent manufacturers from using new formulations of a drug they already make, known as line extensions, to recalculate the Medicaid rebates they have to pay to states.

The announcement was the first major shift of the drug pricing conversation to Medicaid. State Medicaid directors and managed-care plans have bemoaned the need for more control over the prescription drug formulary. Azar also pledged the administration and Congress would force manufacturers to pay more in rebates when they increase their drug prices, a change from the current policy, which he called the "much larger giveaway for drug companies contained in Obamacare."

In addition, Azar touted the administration's recent rules on association health plans and three-year expansion of short-term plans, criticizing states that have already moved to counter the HHS rules with their own regulations. However, he said he wants to work with states on deregulation. He stressed that the administration is working to roll back Obamacare regulations but acknowledged the efforts are limited unless Congress repeals the law.


The U.S. Centers for Medicare and Medicaid Services (CMS) has announced that, for the first time, it will give Medicare Advantage plans the option of negotiating for Part B drugs in a way that both reduces costs and increases the quality of care. For Medicare Advantage plans that also offer a Part D benefit, they will be able to cross-manage across Parts B and D, enabling patients to receive the best medicine whether it is physician-administered or self-administered.

Additionally, CMS noted it is working to ensure that Medicare Advantage plans negotiate in a manner that guarantees patient choice and offers patient protections with guardrails, including that step therapy can only be applied to new prescriptions for individuals who are not actively receiving a particular medicine.

U.S. Department of Health and Human Services Secretary Alex Azar said, "As soon as next year, drug prices can start coming down for many of the 20 million seniors on Medicare Advantage, with more than half of the savings going to patients. Consumers will always retain the power to choose the plan that works for them: If they don't like their plan, they don't have to keep it. We look forward to seeing the results of tougher negotiation within Medicare, and expanding successful negotiation tools throughout our programs."


The Trump administration has proposed to revamp an Affordable Care Act program designed to control soaring Medicare costs by encouraging doctors and hospitals to work together to coordinate patients' care. Using the argument that accountable care organizations (ACOs) have led to higher Medicare spending, the administration could drastically shrink the number of participating health providers.

About 82 percent of the 561 Medicare ACOs are currently set up so that they are not at risk of losing money from Medicare, sharing in any savings they realize. The remaining 18 percent can obtain a higher share of savings but also risk paying back money to Medicare if they fail to meet their savings targets. Medicare officials say those ACOs have been more successful in saving money. The White House plans to phase out the no-risk model starting in 2020, but a poll found 70 percent of ACOs would rather quit than assume such financial risk.

U.S. Centers for Medicare and Medicaid Services Administrator Seema Verma says it is unreasonable to have ACOs that can only make profits but not risk any losses. Current ACOs will have 12 months to transition to a model accepting financial risk while new ACOs will have 24 months, earning Medicare $2.2 billion in savings over the next decade.

Medicine, Drugs and Devices

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Security researchers have discovered vulnerabilities in a range of Medtronic's implanted medical devices that, if manipulated, could lead to injury or death. In new research presented at the Black Hat information security conference, two researchers remotely disabled an implantable insulin pump, preventing it from delivering the lifesaving medication, and then took over a pacemaker system, allowing them to deliver malware directly to the computers implanted in a patient's body.

Jonathan Butts of QED Secure Solutions and Billy Kim Rios of Whitescope.io demonstrated that hackers could modify the system invisibly, while ensuring that any pacemaker connected to it would be programmed with harmful instructions. Hackers can both issue and deny a shock, Beck added, warning that withholding treatment can be as damaging as active attempts to harm.

The pair criticized Medtronic for its slow response to the discoveries, which they first reported to the manufacturer more than a year ago, and its attempts to talk down the weaknesses. In its cybersecurity alerts, the company said the attacks were not possible remotely, and it did not detail the extent of the weaknesses. Medtronic has said it will not fix the vulnerabilities discovered, instead recommending patients and doctors exercise caution with the networks to which they connect the devices. The company says the flaws pose a "low [acceptable]" risk to patient safety.


A report from the U.S. National Institute of Standards and Technology (NIST) details how organizations can use open source and commercially available tools to keep care recipients' information secure on mobile devices. The guide cites specific capabilities of products that an organization can incorporate within its existing infrastructure. In an ideal scenario, a health system should use open source and commercially available tools to ensure beneficiary information is safe when caregivers use mobile devices to share data amongst themselves.

"We recommend that organizations implement a continuous risk management process as a starting point for adopting this or other approaches that will increase the security of EHRs," NIST says. The Cleveland Clinic's Vugar Zeynalov notes, "Leveraging mobile technology to increase quality of care and relieve pressures on providers is a cornerstone of the modern digital hospital. This guidance is a practical foundation to opening up new possibilities for caregivers while maintaining our obligation to [beneficiary] safety and privacy."


Health advocates say a new federal policy aimed at reducing drug prices could negatively affect patients, especially those with chronic conditions. Under the new policy, some private insurers will have the option of requiring patients to try less expensive drugs before trying more costly ones. The policy applies to Medicare Advantage Part B. According to U.S. Centers for Medicare and Medicaid Services Administrator Seema Verma, the step-therapy policy "gives the plans the ability to negotiate better deals with the manufacturers. It may help them negotiate better discounts, encourage drugmakers to lower costs and encourage patients to choose high-value medications." Plans that participate will need to pass more than half of any savings on to patients, using lower premiums or gift cards.

However, Ellen Albritton, a senior policy analyst at Families USA, notes that with the policy, "Consumers may have to go through one or more drugs before they can get a particular treatment they really need. This policy, instead of really getting at the heart of the matter of lowering high drug prices, is putting up more barriers between patients and the drugs they need to stay healthy and live." The Pharmaceutical Research and Manufacturers of America has also expressed "serious concerns" with the policy, saying it could delay some patients from accessing needed medicines. The policy takes effect on January 1 and applies to new prescriptions only.