News From ACFAS

---

Flex your coding and surgical muscles the day before ACFAS 2019 in New Orleans begins with three new pre-conference workshops set for Wednesday, February 13. Choose from:

Coding and Billing for the Foot and Ankle Surgeon
(7:30am–5:30pm, 8 CE contact hours)
Did you miss the last Coding and Billing seminar of 2018? No worries! Join us in New Orleans for a full day of practical tips and tools to help you maximize your reimbursement, make sense of modifiers and code for higher-level E/M services.
Register Now

Lateral Ankle Instability: It’s All About the Soft Tissues and the Bone
(7am–Noon, 4 CE contact hours, includes wet lab)
Learn the latest surgical solutions for pes cavus and lateral ankle instability in this hands-on cadaveric workshop. Practice repair options for mechanical deformities and soft tissue to achieve ankle stabilization.
Register Now

Grand Rounds: Optimizing Outcomes for Your Most Challenging Cases
(Noon–5pm, 4 CE contact hours, includes wet lab)
Digestible, evidence-based presentations on four bread-and-butter topics—First MPJ Fusion, Flatfoot (Non-Fusion Realignment), Ankle Fusion (Non-Charcot) and Bone Graft Harvest Options—include labs plus the chance to “choose your own adventure.” Hear cases submitted by audience members after each lab then discuss recommendations and outcomes.
Register Now

Visit acfas.org/neworleans for more details on these workshops and all that awaits you in New Orleans! With flu season underway, be sure to incorporate Guide to Infection Prevention for Outpatient Podiatry Settings and Pocket Guide to Infection Prevention for Outpatient Podiatry Settings in your practice.

ACFAS recently partnered with The Joint Commission, the U.S. Centers for Disease Control and Prevention and other healthcare specialty organizations to develop these free guidelines, also known as Adaptation and Dissemination for Outpatient Infection Prevention (ADOPT) Guidance, to help ensure patients receive care in environments that minimize or eliminate the risk of healthcare-associated infections.

Download the guides now at acfas.org/ADOPT or visit cdc.gov for more information. Are you considering a fellowship but have questions about the application process? Then check out our latest podcast, “The ABCs of Applying for Fellowship,” to hear a panel of your peers spell out the steps involved in the process while sharing their own personal fellowship experiences.

Learn how to:

• Narrow your focus when selecting a fellowship program
• Present yourself as a marketable fellowship candidate
• Avoid common mistakes when applying to a program
• And more!

Access the podcast now through the ACFAS e-Learning Portal, and visit acfas.org/e-learning regularly for other new free products to enhance your learning at your convenience. ACFAS’ e-Learning on demand offers a number of CME hours through Clinical Sessions, Surgical Techniques DVDs and e-Books that allow you to earn CME within your timeframe. Check out the ACFAS Education Calendar for face-to-face CME programs as well.

Our online resources are available 24/7, and new programs are added to the e-Learning catalogue every six weeks to give you a broad selection of options to explore. Visit acfas.org/e-learning to access these tools and so many other resources to keep you connected. A big THANK YOU and congratulations to ACFAS’ loyal and dedicated members who have been a part of the College since 1979! In appreciation, these 40-year members receive automatic Life Membership status with ACFAS.

For 2019, the ACFAS Board of Directors honors:

• Nicholas Bradlee, DPM, FACFAS, Troy, MI
• D. Hugh Fraser, DPM, FACFAS, Powell, WY
• Gerard J. Furst, DPM, FACFAS, East Setauket, NY
• Donald R. Green, DPM, FACFAS, San Diego, CA
• Michael A. Mineo, DPM, FACFAS, Houston, TX
• David C. Novicki, DPM, FACFAS, Milford, CT
• Robert L. Potempa, DPM, FACFAS, Chicago, IL
• Scott E. Rickoff, DPM, FACFAS, Pensacola, FL
• Randall J. Sarte, DPM, FACFAS, Sacramento, CA
• Barry L. Scurran, DPM, FACFAS, Alamo, CA
• Gary J. Sherman, DPM, FACFAS, Brooklyn, NY
• Larry Weiss, DPM, FACFAS, Detroit, MI

Foot and Ankle Surgery

---

Symptomatic cystic lesions of the talus are rare. Traditional operations typically do not provide visualization to reveal the deep structure of the lesion and could cause cartilage damage or other severe traumatic injury. In this study, researchers reported an operative technique to reach the cystic lesion without talar cartilage damage, remove the lesion and fill the defect with a bone graft assisted by anterior arthroscopy and evaluate its safety and reliability for future study.

Seven cases of talar bone cyst were included. The patients were placed in the supine position after anesthesia induction and noninvasive ankle traction were applied. Standard anteromedial and anterolateral portals were established to observe the ankle; the distal end of the medial approach was moderately enlarged to 2 to 3 cm. The biopsy specimen of the cyst was obtained under arthroscopic guidance; the cyst wall was abraded and the sclerotic rim drilled. Arthrocare radiofrequency ablation was performed to prevent recurrence. The defect was tightly impacted with autologous or allograft cancellous bone. All cysts in these cases were located in the medial talus; anteroposterior radiographs and computed tomographic coronary scan showed a cyst diameter of >1 cm. Intraoperative inspection showed a tiny chondral gap on the talar dome in one case and on the medial wall of the talus in one case; no cartilage injury was found in the remainder. Two cases were impacted with grafted autogenous iliac bone into the talar defect and five cases with allograft cancellous bone. Computed tomography confirmed that the cysts had healed, with no signs of recurrence found in any patient at one year postoperatively. The mean American Orthopaedic Foot and Ankle Society ankle-hindfoot scale score increased from 65 preoperatively to 91 points postoperatively, a statistically significant difference.

No complications developed and no reoperations were required postoperatively. The researchers concluded that arthroscopically assisted anterior treatment with autologous or allograft bone graft is an effective method for symptomatic large talar bone cysts.


First metatarsophalangeal (MTP1) joint arthrodesis is described as a safe and effective procedure, but it has complications that may require surgical revision. These complications are rarely examined. Researchers sought to determine the incidence and outcomes of revision surgery after MT1 arthrodesis.

In this multicenter retrospective study between January 2014 and December 2015, 190 forefoot revisions in patients who had previously undergone MTP1 arthrodesis were included by eight surgeons. No exclusion criteria existed, and all patients had at least one year of follow-up. Over the same period, 958 primary MTP1 arthrodesis procedures were performed.

The mean time to revision was 4.6 ± 10.9 years. At a mean follow-up of 20.5 ± 7.4 months, 158 cases were available for analysis in 135 women and 20 men who had a mean age of 67.1 ± 10.5 years. These revision procedures were carried out because of discomfort related to the hardware at the arthrodesis site (54 percent), nonunion (14 percent), malunion (8 percent) metatarsalgia or claw toe (11 percent) and first interphalangeal (IP1) joint disorders (8 percent). The mean postoperative scores were 75 ± 13.9 for the AOFAS and 65 ± 19.6 for the SF36 total. In the nonunion cases, removal of the hardware led to better outcomes than repeating the arthrodesis procedure. Osteotomy in the malunion cases healed successfully. In the cases of IP1 osteoarthritis, secondary arthrodesis or arthroplasty led to good outcomes.

The researchers concluded that relative to published results of primary MTP1 arthrodesis, the outcomes in this series of revision MTP1 arthrodesis surgery cases are practically equivalent, thus considered acceptable.


Brachymetatarsia is defined as the pathological shortening of a metatarsal bone. The main surgical treatment options are extension osteotomy, interposition of a bone graft and callus distraction. Typically, a bone graft from the iliac crest is used for the interposition osteotomy. The operative technique of graft extraction from the fibula has not yet been described in the literature.

Eight feet with brachymetatarsia in five patients were evaluated retrospectively. The minimum follow-up period was two years. A central osteotomy on the metatarsal bone was performed via a dorsal V/Y skin incision. A graft was obtained from the anterior fibula. The graft was inserted and fixed by a locking plate. Additional soft-tissue procedures were performed.

Researchers had bony consolidation in all cases. The mean extension was 9.01 mm. This corresponded to a mean 20.3 percent extension of the entire metatarsal. High patient satisfaction as well as high satisfaction regarding the cosmetic results were achieved. No postoperative complications were observed. The range of motion of the metatarsal-phalangeal joint IV was 20 percent less preoperative in terms of plantar flexion. Standing up on tiptoes was possible in all patients postoperatively. One patient reported mild symptoms after sports activities.

The graft adapts to the metatarsal IV bone because of its anatomy. As the study showed, harvesting from the distal fibula causes no functional restriction. In terms of wound and bone healing as well as pain symptoms, this method should be considered as an alternative to the standard iliac graft.

Practice Management

---

The Association of American Medical Colleges anticipates a shortfall of between 42,000 and 120,000 physicians by the year 2030. While no clear solutions exist for the impending doctor shortage, gaining a better understanding of what drives young or early career physicians will help private practices and hospital administrators prepare for the next generation of talent.

The first thing healthcare organizations can start doing to recruit and retain millennial doctors is to focus on culture and purpose in the work environment. In a recent survey from CompHealth, a majority of millennial doctors indicated that organizational culture elements were the most influential when looking for employment. Millennial doctors want good work-life balance (63 percent), culture fit (60 percent) and location (60 percent) at their jobs. Compensation was important (49 percent), but it was not the critical determining factor. In other words, attracting and retaining young physicians will not come by simply raising salaries. Companies that reinforce positive culture and emphasize work-life balance will have an advantage when it comes to recruiting and retention.

In addition, healthcare organizations should enable employees to pursue outside passions and offer them new experiences. Millennial physicians will pursue multifaceted careers. Enabling young doctors to continue their education, develop specializations and pursue other interests will benefit organizations, employees and ultimately patients. Administrators should consider arranging visits from outside experts and coordinating schedules to allow time to attend classes and conferences. As millennial physicians continue to develop their own careers and as the physician shortage deepens, offering new avenues and experiences could be a critical stepping stone for doctors and a valuable recruiting strategy for healthcare organizations.


The overwhelming majority of older adults said they would be willing to stop taking at least one of their medications if their doctor said this was possible, according to a study published in JAMA Internal Medicine. "To our knowledge, this is the first nationally representative study of attitudes toward deprescribing among older Medicare beneficiaries ... This suggests that clinicians can be reassured about broaching the topic of deprescribing with their older patients," the researchers wrote.

The researchers analyzed data from almost 2,000 Medicare beneficiaries and found that 92 percent of respondents were willing to discontinue at least one of their medications with the permission of their physician. In addition, two-thirds said they wanted to reduce the number of medications they were taking and nearly half agreed or strongly agreed that they believed they were taking a large number of medications. However, 89.5 percent of respondents agreed or strongly agreed that they needed all of their medications. "These seemingly contradictory beliefs (i.e., being willing to have a medication deprescribed but also thinking that their medicines are necessary) may reflect a combination of traditional deference to physician recommendations coupled with a medical culture focused on prescribing and starting medications rather than deprescribing," the authors wrote.

The patients who were most willing to stop their medication were individuals taking at least six drugs, older adults with a greater number of medical conditions, those in good health and beneficiaries aged 65 to 74 years old versus those older than 85. "Physicians considering deprescribing as part of comprehensive, patient-centered care should be reassured that a majority of older Americans are open to having one or more of their medicines stopped if their physician said it was possible, and two thirds want to reduce the number of medicines that they are taking," the authors concluded.


Patients tend to be hesitant to embrace telemedicine, but those who do report strong satisfaction, according to a research letter published in The New England Journal of Medicine. Researchers at Kaiser Permanente examined telemedicine usage at a health system that had implemented the capability for all clinicians to conduct video visits in 2014. They analyzed a total of 210,383 scheduled video visits among 152,809 patients from 2015 through 2017.

Researchers found that 77 percent of visits were related to medicine, pediatrics, dermatology, after-hours care or psychiatry. Of the nearly 81,549 adult primary care video visits, 70 percent of the appointments were with the patient's own primary care provider. More than 90 percent of patients who scheduled a video visit had accessed in-person healthcare in the previous year. Patients were most likely to use smartphones (74 percent) to facilitate video visits, followed by desktop computers (20 percent) and tablets (6 percent). Two-thirds of visits were successfully completed, with patients and physicians connecting via video at the scheduled time. Patients were more likely to successfully connect with their physician remotely when they scheduled a session with their own primary care provider. Finally, 93 percent of patients reported that the video visit met their needs.

"We studied a novel model of integrating telemedicine seamlessly with patients' ongoing clinicians, EHRs and delivery systems, distinct from most direct-to-consumer telehealth-only services," the research letter states. "We found that video visits extended established patient-physician relationships, with the majority of video visits involving familiar clinicians, often the patient's own primary care provider."

Health Policy and Reimbursement

---

The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed that prescription drug manufacturers be required to post the Wholesale Acquisition Cost for drugs covered in Medicare or Medicaid in direct-to-consumer television ads. CMS said the proposed rule aims to give greater transparency to the prices set by drug manufacturers and would provide beneficiaries with the "information they need to make informed decisions based on cost, while concurrently providing a moderating force to counteract price increases."

Under the proposal, the price that must be posted would be for a standard course of treatment for an acute medication, such as an antibiotic, or a 30-day supply of medication for a chronic condition that is taken every month. The posting would be included as a legible textual statement at the end of the drug ad, and the U.S. Department of Health and Human Services would keep a public list of drugs that did not follow this rule with their ads. An exception would be provided for prescription drugs with list prices that were less than $35 a month. CMS is accepting comments on whether the rule should apply to ads in other media forms through December 17, 2018.


For some healthcare providers, the costs of delivering a new Medicare diabetes prevention program (MDPP) may be much higher than the expected reimbursement, according to a recent study published in Medical Care. MDPP targets older Medicare beneficiaries meeting criteria for "prediabetes," estimated to be present in nearly half of U.S. seniors. Payments may cover as little as one fifth of the costs of delivering recommended diabetes prevention services in safety net healthcare settings, the findings showed.

The researchers analyzed the costs of and expected reimbursement for providing MDPP services to 213 Medicare beneficiaries with prediabetes or other diabetes risk factors in Denver's safety net healthcare system. Most patients were of minority race/ethnicity and classified as low-income. The average projected reimbursement was about $139 per patient. Outcomes of the MDPP intervention were not as good in this group of largely minority, low-income Medicare beneficiaries. Less than 5 percent of participants met all milestones (attendance and weight loss) needed to reach the maximum payment of $470 for a full year of services. By comparison, the costs of delivering the program were estimated at $800 per patient. Subtracting the average payment of $139, there was a $661 gap between the costs of the program and the expected payments.

Reimbursement provided by Medicare will fall short of covering the costs for providing MDPP services, especially for healthcare providers serving diverse, underserved patient populations, the authors concluded. They proposed that reimbursing the full beneficiary cost of $800 per patient would pay for itself within the first year due to healthcare expenditures avoided and would bring an even larger return on investment in later years.


The U.S. Department of Health and Human Services (HHS) Health Resources and Services Administration (HRSA) has announced $293 million in awards to primary healthcare clinicians and students through the National Health Service Corps (NHSC) and Nurse Corps programs. "These programs connect primary care providers with the rural, urban and tribal communities across the country that need them most," said HRSA Administrator George Sigounas, MS, PhD. "In addition to providing essential medical and dental care, these clinicians are on the front lines helping to fight pressing public health issues, like the growing opioid epidemic."

The NHSC and Nurse Corps programs build healthy communities by providing scholarships and loan repayment to healthcare providers in exchange for working in areas of the country with limited access to care. Currently, an estimated 13 million patients receive care from more than 12,500 NHSC and Nurse Corps clinicians. Another 1,725 primary care students are either in school or in residency preparing for future service with the Corps programs.

More than 3,600 of these NHSC members are currently providing behavioral healthcare services, including medication-assisted treatment and other evidence-based substance use disorder care, in high-need areas. HRSA continues to invest in expanding access to substance use disorder treatment in rural and underserved areas. The HHS awards will support eight programs, including the National Health Service Corps Scholarship Program, which received $47.1 million, the National Health Service Corps Loan Repayment Program, which earned $142.1 million and the National Health Service Corps Students to Service Loan Repayment Program, which was awarded $19.3 million.

Medicine, Drugs and Devices

---

Media focus on the opioid crisis has not diminished the desire and expectation for postoperative painkillers, according to a patient survey conducted at Thomas Jefferson University Hospital in Philadelphia. The responses were culled from 503 adults planning to have joint replacement, back or abdominal surgery or ear, nose and throat operations—all of whom said they expected to receive some type of pain medication after their procedure.

Respectively, 37 percent and 18 percent of the survey takers figured they would receive acetaminophen or a nonsteroidal anti-inflammatory drug. More than three quarters of poll participants, however, believed they would be treated postoperatively with opioids, which were overwhelmingly perceived to be the optimal pain management approach after surgery—even by those who did not expect to receive them.

Despite patients' expectations, research indicates that "opioids aren't necessarily more effective," said Thomas Jefferson anesthesia resident Nirmal Shah, DO. "Clearly, we need to provide more education to bridge that gap and help patients understand that there are many options for pain relief after surgery, including other pain medications, such as acetaminophen and ibuprofen."


The U.S. Food and Drug Administration (FDA) wants medical device manufacturers to package their products with a list of their hardware and software components, according to new draft guidance on medical device cybersecurity. The so-called "cybersecurity bill of materials" would help end users keep a closer eye on the security of their medical devices, ensuring that safeguards are in place to keep the devices functioning even if vulnerabilities exist.

Many in the industry have long called for bills of materials. "We don't necessarily have a secure supply chain in general," said David Ross, principal and cybersecurity growth leader for Baker Tilly's risk, internal audit and cybersecurity practice. "A bill of materials might help your staff when you're procuring these devices. You could do a risk assessment and quantify the overall risk from a cyber perspective for any given device."

In the new draft guidance, the agency distinguishes between two kinds of medical devices: those that connect to other devices or networks and that could lead to patient harm if hit by a cyberattack, and those that are not connected to other devices or networks and do not pose similar risks.

FDA recommends all devices require user authentication before device software or firmware can be updated. Device manufacturers should also include information about when they will stop offering security patches and software updates with their products. When in use, devices should be designed to reject connections that have not been authorized by default. Device makers should also limit which users can access certain functions of the device by requiring authentication at certain points, according to the guidance. FDA recommended that they be able to detect cyberattacks while in use and then notify users of the attacks.


Nearly two-thirds of hospitals and health systems have ramped up investment in opioid medication management in the last 12 months, according to a recent survey by Vizient, Inc. of its members across the United States. The survey examined how facilities are dealing with the opioid crisis and specifically what changes they are implementing, what is working and the challenges in managing resources.

The most commonly implemented programs included prescriber education (78 percent), new technologies to monitor prescribing (56 percent), new alternatives for acute pain management (54 percent), prescriber limits on dosage/quantities (44 percent), safe disposal of old medications (43 percent) and opioid stewardship program (33 percent). Dosage guidelines for acute care patients upon discharge received the best reviews with 74 percent of those from facilities that have put them in place. Staff who adopted the new dosage guidelines feel the new rules were extremely or very effective. Adding new staff to help manage the opioid epidemic (67 percent) and new technologies to monitor opioid prescribing (50 percent) were the next two most effective.

The study also found that hospitals are being forced to reallocate resources to deal with the opioid crisis. In addition, although 47.8 percent of respondents see patients who show drug-seeking behaviors multiple times per day, daily or nearly every day, 78 percent of respondents said the opioid crisis has not affected their ability to serve patients. Almost three out of 10 reported that the increased volume of opioid-related admissions are causing longer wait times.