News From ACFAS

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Face your toughest forefoot injury and deformity cases head on when we get “In the Trenches” for the first time, October 6–7 in Providence, Rhode Island. This new On the Road regional program includes an interactive seminar, hands-on labs plus ample opportunity to work through the surgical challenges you experience in your practice.

Friday evening begins with the presentation, “Controversies and Complications,” followed by an open discussion during which you can share your own work cases and enjoy refreshments. Saturday features lectures presented by expert faculty as well as two sawbones labs on the Big 6 Techniques and osteotomies. Faculty will close with tips on:

• Peroneal tendons
• Achilles tendon rupture
• Ankle fusion vs. ankle replacement
• Retrocalcaneal AICT/FHL transfer
• Perioperative myths and folklore

Visit acfas.org/education to register today since space for this course is limited. The ACFAS Nominating Committee seeks dedicated members to serve on the College’s Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to help lead the profession, send your nomination application by October 1, 2017.

Visit acfas.org/nominations for the nomination application and complete details on the recommended criteria for candidates. For more information, contact Executive Director Chris Mahaffey via email or (773) 693-9300. Questions regarding eligibility criteria should be directed to Nominating Committee Chair Sean Grambart, DPM, FACFAS, via email or (217) 671-3634.

The Nominating Committee will announce recommended candidates to the membership no later than November 23. Candidate information and ballots will be emailed to all voting members no later than January 7, 2018. Electronic voting ends on January 22, 2018. New officers and directors will take office during ACFAS 2018, March 22–25 in Nashville. ACFAS’ national PR campaign, Take a New Look at Foot & Ankle Surgeons, will exhibit next week at the American Academy of Family Physicians’ (AAFP) national conference in San Antonio. How often do FPs consult with you or refer patients to you? Let us know by voting in this month’s poll at right.

View real-time poll results at acfas.org, and watch for Take a New Look highlights from the AAFP conference in the September 20 issue of This Week @ ACFAS. Don't miss out on potential funding for your latest research—apply for the ACFAS Clinical and Scientific Research Grant by September 15, 2017.

For the past 11 years, the program has supported ACFAS members' foot and ankle surgical research as well as the College’s core goal of advancing evidence-based medicine (EBM) to improve patient care.

This year, the ACFAS Research-EBM Committee would like to see studies on hammertoe implants and total ankle implants vs. screws. Visit acfas.org now to download the application. Direct any questions about the research grant to research@acfas.org.

Foot and Ankle Surgery

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Classification systems for hallux rigidus suggest that as radiographic changes progress, symptoms will concurrently increase in severity. However, symptom intensity and radiographic severity can be discordant for many patients. Researchers studied the correlation between hallux rigidus grades and the Foot and Ankle Ability Measure (FAAM) scores to better understand this relationship. They retrospectively reviewed weightbearing radiographs of the foot and FAAM Activities of Daily Living (ADL) questionnaires for 84 patients with hallux rigidus. The Spearman rank coefficient was used to correlate clinical-radiographic hallux rigidus grade with FAAM ADL scores. In 84 patients, the clinical-radiographic grade for hallux rigidus showed no relationship with FAAM ADL score but showed moderate correlation with patient age. The researchers found that advancing radiographic changes in hallux rigidus did not correspond with patient symptoms as measured via FAAM ADL scores. They concluded that the reliability and validity of current grading criteria for hallux rigidus may require further exploration.


Lysyl oxidase (LOX) is an extra-cellular matrix-modifying enzyme that has been linked to cell proliferation, metastasis, angiogenesis and wound healing. This study was designed to examine the association of LOX gene polymorphism G473A, G > A, (rs1800449) located in exon 1 of the LOX gene in diabetic subjects with and without diabetic foot ulcers (DFU) and the impact of its expression on DFU. Genotypic analysis of 906 samples showed a significant increase in the presence of 'A' allele in type 2 diabetes mellitus (T2DM) and DFU when compared to controls. Allele wise analysis showed a higher frequency of 'A' allele in the T2DM (36.23 percent, OR 1.069, P value 0.29) and DFU (41.69 percent, OR 1.195, P value 0.003) when compared to control subjects (33.17 percent). Interestingly, real-time RT-PCR results showed significantly increased transcript levels of the LOX gene with the AA genotype in DFU subjects compared to levels of the AA genotype in T2DM and control subjects. This finding predicts that there is an association between LOX gene polymorphism (G473A) and diabetes and DFU. Thus, this study merits further evaluation on a mechanistic impact of this gene, the researchers conclude.


Intraoperative pedobarography has the potential to aid surgical decisions, but no parameters exist to guide its use. This study compared supine plantar pressures between flatfoot patients and controls using a previously validated intraoperative pedobarographic device and examined associations between supine, walking and standing plantar pressures. Ten preoperative patients with stage II adult-acquired flatfoot deformity were compared to 10 healthy controls. Supine plantar pressures were assessed using the pedobarographic device. Standing and walking plantar pressures were assessed with an EMED-XT sensor array (Novel), and maximum force (MF) and peak pressure (PP) were calculated for nine anatomical foot regions adjusting for age and BMI. No differences in plantar pressures were found between flatfoot patients and controls in the supine or standing positions. During walking, flatfoot patients had greater MF of the first, second and third metatarsals and greater PP of the first and second metatarsals than controls. Supine MF and PP were both strongly positively correlated with their respective pressure measurements for both standing and walking in multiple foot regions. The researchers found that the device did not show differences between supine plantar pressures of flatfoot patients and healthy subjects, highlighting the limitations of intraoperative devices in guiding flatfoot correction. The differences between flatfoot and controls during walking and the correlations between supine and walking conditions indicate that dynamic plantar pressures are a more useful parameter in guiding flatfoot reconstruction.

Practice Management

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Physician practices can bolster their online reputations by coaxing patients to post online reviews. “Doctors need to get proactive in asking their patients for feedback,” says MedPilot cofounder Matt Buder Shapiro. “To increase the chances of receiving feedback, you need to directly ask for it, either in person at the end of a visit or digitally through email/text message. Encouraging feedback in general, and not just pleading for good reviews, will make patients much more likely to oblige.” Primary care physician Janice Johnston concurs. “When a patient is a promoter of the practice and has an amazing story to tell, we ask if they would mind sharing on social media, and they usually are very willing to do so,” she notes. “Having positive reviews and a presence on the Web definitely helps when patients are searching for a new provider, especially for millennials.” Physicians can follow some simple strategies to encourage patient reviews, such as listing the practice with online review sites to make it easy for people to find and leave reviews, creating incentives for staff to encourage patients to leave a review and highlighting patients who have left positive reviews in marketing materials. Negative reviews can also be opportunities for physicians to engage with patients and hopefully resolve issues that prompted the negative reviews.


Using electronic health records (EHRs) and maintaining patient engagement represent a challenge for many healthcare facilities. EHR has simplified some tasks, but regulatory requirements must also be considered. Meanwhile, positive patient outcomes remain important as well. Experts say doctors must not allow computers and technology to completely distract them when providing care. The following tips can help professionals find balance: use workflow shortcuts that include EHRs in patient interactions; include and educate patients on EHRs when they are being used; and dedicate time away from computers to build relationships with patients.


Building patient referrals demands patience, and practices can make gains in such referrals by first establishing a strong online presence and reputation. This requires an interactive website and presence on major review sites with positive reviews of the practice, while visibility on Google Maps with accurate contact details is a must. Blogging can also be helpful as a tool for drawing traffic to the website. Also recommended is training staff appropriately on how to treat patients to ensure a positive experience that motivates them to refer others to the practice. Staff should pay close attention to patients’ concerns and inquiries, proactively devise solutions and also thank patients for their feedback. Patients often require calls, texts or emails after inpatient care, while practices should cultivate expertise by organizing health camps in the local community on general health issues, or by participating in engagement programs in nearby hospitals. Also advised is for practices to get in touch with and befriend new physicians in the area.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) has announced it will abandon two bundled-payment models: the Episode Payment Models and the Cardiac Rehabilitation incentive payment model, which were scheduled to begin on January 1, 2018. In addition, the geographic mandatory participation areas for the Comprehensive Care for Joint Replacement model will be cut from 67 to 34 under the proposed rule. In the remaining mandatory participation areas, hospitals with fewer than 20 joint replacements over three years will be excluded starting in February 2018, but they can voluntarily participate in the model if they so choose. Up to 470 hospitals are expected to continue to operate under the model, down from 800 if no changes were made. Michael Thompson, president and CEO of the nonprofit National Alliance of Healthcare Purchaser Coalitions, says, "Medicare backing away from some of that is a step backward, and hopefully a temporary one. The U.S. Department of Health and Human Services (HHS), through Medicare and Medicaid, is one of the largest players in the system, accounting for more than half of all payments, and when it adopts this value-based approach, it quickly sets a tone for the entire industry." He believes that the loss of HHS dedication to value-based reimbursement will lead health plans to put even more emphasis on engaging consumers in optimal use of resources and achieving better outcomes.


The August 2017 Altarum Institute Center Health Sector Trend report reveals that healthcare spending growth slowed in 2016, with spending rising by 4.6 percent in 2016. Estimates based on new data suggest this downward trend will continue for the first half of 2017 at 4.4 percent. Altarum said the estimates illustrate the impact of expanded coverage, and its subsequent leveling off, on healthcare utilization. Coverage expansion was concentrated in 2014 and 2015, leading to a jump in health services utilization. That peaked at 5.1 percent in 2015. "Coverage leveled off in 2016 and, in response, the growth in health services utilization has been trending back toward preexpanded coverage rates," Altarum said. Healthcare price growth has also dropped in 2017, from two percent in the first quarter to 1.6 percent in the second quarter. Although much higher than healthcare services, prescription drug price growth slowed to 3.6 percent in the second quarter of 2017. Health employment grew an average of 21,000 jobs per month during the first five months of 2017 then unexpectedly rebounded to 38,000 in June and July. The jump in June and July was a surprise and was focused mainly in ambulatory settings. "Growth averaged 32,000 during 2015 and 2016, and the decline in monthly growth during the first five months of 2017 was expected due to slower growth in healthcare utilization driven by the leveling off in expanded coverage," Altarum said. The American Hospital Association's February 2017 Cost of Caring report also illustrated the increased utilization in 2014 and 2015, due to expanded healthcare coverage and more intense utilization of services like chronic disease management.


A significant number of healthcare providers feel unfamiliar with the impact of MACRA and whether they qualify for MACRA participation, according to a recent survey of about 1,000 healthcare experts by NueMD. Sixty-three percent of respondents said they work at small practices of one to three providers, which are expected to bear the weight of MACRA. Half of respondents were unfamiliar with the bill—marked by a general lack of knowledge on the subject. Respondents who understand MACRA are optimistic, with 39 percent who identified as very familiar with MACRA saying it will have a beneficial financial impact. Larger practices were more convinced of the positive impact than smaller practices. Meanwhile, 62 percent of respondents said they were unsure of MACRA's impact on patient care. Providers very familiar with MACRA believe care will improve, while all others believe it will get worse. Fifty-eight percent were uncertain of the bill's administrative reporting impact, although both large and small providers concurred that MACRA will entail more time spent reporting. Sixty-five percent of respondents said they are unsure of the financial impact MACRA will have on healthcare costs, although 20 percent predicted a negative impact.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration (FDA) has announced in a new guidance document that it will increase its focus on "real-world" data as part of its oversight of medical devices. In the past, FDA used data from device-makers when making a regulatory ruling. FDA wrote, "However, FDA recognizes that a wealth of data covering medical device experience exists and is routinely collected in the course of treatment and management of patients."


Many San Diego physicians are taking their patients off of the popular Type 2 diabetes medication Invokana after a large industry-sponsored trial determined it doubled the risk of lower limb amputations versus those taking a placebo, even though the trial also indicated the drug's benefits outweigh that danger. On May 16, the U.S. Food and Drug Administration (FDA) released a black box warning about amputations, urging patients taking canagliflozin, sold as Invokana, Invokamet and Invokamet XR, to contact their physicians immediately if they notice pain or tenderness, sores, ulcers or infections in their legs or feet. Approximately 50 percent of amputations occurring among patients in the trial were of toes, while the rest were across the foot, at the ankle, below the knee and above the knee. FDA suggests physicians should weigh factors that predispose patients to amputations, including prior amputations, peripheral vascular disease, neuropathy and diabetic foot ulcers, before prescribing canagliflozin. In addition, the agency says physicians should monitor patients for ulcers, sores, pain or tenderness and should discontinue canagliflozin if these complications occur.


The U.S. Food and Drug Administration (FDA) says it will collect drastically higher fees for some applications in accordance with the Generic Drug User Fee Amendments of 2017 and the Medical Device User Fee Amendments of 2017. The higher fees are a result of negotiations between the industry and FDA, which was part of a five-year reauthorization of the FDA user fee programs. Those programs were signed into law in August. The new rates apply from October 1, 2017, through September 30, 2018.