News From ACFAS

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It’s that time of year again: dues reminders for the 2014 calendar year of membership have been mailed to all Associate and Fellow members. Dues can be paid online now at acfas.org/paymydues, or by mail or fax once your reminders arrive at your office or home. Payment is due by December 31, 2013.

Be sure to take advantage of all ACFAS has to offer, now and throughout the year. Visit the online ACFAS Member Center to learn more about the benefits your membership provides. College membership brings you in contact with the best and the brightest foot and ankle surgeons in the world. Here’s to another great year of value in your membership! Take advantage of all the 2014 Annual Scientific Conference in Orlando has to offer—attend one of four first-class pre-conference workshops to re-energize your surgical techniques or augment your business approach to managing your office. Each pre-conference workshops take place Wednesday, February 26 – one day before the full conference starts. Register today at acfas.org/Orlando and choose the workshop best suited for you:

• Diabetic Deformity: Master Techniques in Reconstruction
  Gather the knowledge to effectively evaluate and manage diabetic patients with complex deformities while gaining experience through the hands-on execution of procedures for complex deformities in this cadaveric workshop. ACFAS faculty will guide participants through risk stratification in limb salvage versus limb amputation and share experience in midfoot, rearfoot and ankle reconstruction as well as amputations.
  
  
• Monday Morning Trauma: Advanced Reconstruction Techniques
  Challenge yourself to learn the best approaches and techniques to conquer the many traumas often seen after active weekends. Learn hands-on surgical techniques from skilled faculty who will inspire you to think strategically and efficiently while dealing with difficult cases requiring tactical decision-making.
  
  
• Advanced Tendon Repair and Fixation
  Walk away with a refreshed energy for how to effectively evaluate and measure tendon ruptures and injuries as well as an enlivened understanding of techniques you can use in this collaborative cadaveric workshop.
  
  
• Perfecting Your Practice: Coding/Practice Management Workshop
  This interactive, comprehensive practice management workshop covers pertinent issues in surgical coding, modifiers, evaluation and management codes, and durable medical equipment. Gain a thorough overview of the tried and true concepts and skills required to manage today's medical practice and learn how to measure the indicators of a successful practice from an experienced panel of foot and ankle surgeons.

Last year, an organization that went by the name Exhibitors Housing Services (EHS) falsely represented itself as the official housing partner by calling and soliciting ACFAS attendees and exhibitors. The College would like to remind you again this year that our true official housing partner is OnPeak, LLC. If you receive a call from any organization other than OnPeak, please do not give your credit card information or cash deposits.

You can safely make your ACFAS 2014 hotel reservation by visiting acfas.org/orlando and selecting “Make Hotel Reservation." If you have any questions, please call ACFAS headquarters at (773) 693-9300. Check out the latest Scientific Literature Reviews released November 1, and read about findings from studies published in other scientific specialty journals that may impact your surgical cases. These time-saving summaries are written by podiatric surgical residents and feature topics you might not already have on your radar. Here’s a sneak peak at some of this month’s reviews:

• Do Malignant Bone Tumors of the Foot Have a Different Biological Behavior than Sarcomas at Other Skeletal Sites? from Sarcoma, reviewed by Laura Bohman, DPM
• Pediatric and Adolescent Intra-Articular Fractures of the Calcaneus from the journal Orthopaedic Review, reviewed by Jennifer A. Lipman, DPM
• Barefoot Sports Injury on Hallux: A New Classification by Injury Mechanism from The Journal of Orthopaedic Trauma, reviewed by Jason Kayce, DPM

To see the full list of SLRs for the month of November, or for past collections, visit acfas.org/SLR.

Foot and Ankle Surgery

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A new study has concluded that the use of free non-vascularized fibular strut bone grafts (FNVFGs) is effective at treating some cases of lower extremity fractures where there are post-traumatic bone defects of more than four centimeters. During the study, 10 patients underwent a procedure in which subperiosteally-harvested FNVFGs were held in place by screw fixation of the strut ends to the ends of the bone defect. This procedure was used to correct bone defects that were seven centimeters in length on average. All of the grafts united at both ends within an average of six months. Nine patients were able to walk without assistance, though one required the use of a walking stick.


Orthopaedic surgeons in South Korea have performed a study that examined the incidence and characteristics of periprosthetic osteolysis and its association with clinical outcomes following total ankle arthroplasty (TAA) using the HINTEGRA ankle system. The surgeons analyzed data on 99 ankles in 90 patients who underwent primary TAA and were followed-up with after an average of 40.8 months. Radiologic evidence of osteolysis was seen in the radiographs of 37 of the ankles, 10 of which displayed continuous progression over the study period. The study also determined that helical computed tomography (CT) scans were more accurate than radiographs at identifying and measuring periprosthetic osteolysis in TAA. In addition, there was no major association between the presence of osteolysis and clinical and radiologic outcomes. The study concluded that early diagnosis and careful evaluation of osteolysis could make it possible to perform limited revision surgery in TAA-treated ankles in which the prosthesis is about to fail.

Practice Management

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The Healthcare Financial Management Association (HFMA) has rolled out the final version of a set of best practices governing communications between healthcare providers and patients concerning billing issues. Among the issues covered by the voluntary set of best practices are when and where a healthcare provider should initiate a conversation with a patient on a financial matter, as well as who should be involved in such a conversation. The guidelines call on healthcare providers to allow patients to include a family member or some other type of advocate in discussions about billing issues. In addition, the guidelines discuss how to handle care for patients with outstanding balances. Patients who need financial assistance, the guidelines say, should be given information about financial assistance programs when they are discharged. The guidelines were developed at the behest of the billing and collections company Accretive Health, which created the panel that devised the best practices after its debt collection practices and alleged privacy violations attracted the attention of officials in Minnesota. Accretive Health ultimately settled the matter with Minnesota's attorney general.


Vanderbilt University Medical Center's Center for Professional and Patient Advocacy is touting the success of its "peer messengers" program, which is designed to help doctors improve their performance and avoid malpractice suits following patient complaints. Under the program, doctors whose practices are not meeting expectations or are not adhering to best practices are selected for counseling performed by fellow doctors who are chosen by hospital leadership to serve as peer messengers. These messengers schedule confidential visits with doctors who have been identified for counseling in which they share data about specific behaviors or clinical outcomes, albeit in a respectful and non-confrontational manner. Messengers are instructed to avoid trying to correct a particular doctor's problems and instead begin a hospital intervention process aimed at helping the physician. This intervention can take place over an extended period of time if need be. A study published in The Joint Commission Journal on Quality and Patient Safety has found that the program has been successful in improving physicians' work. The four-year study evaluated 375 doctors thought to be at high risk for possible litigation and found that 64 percent of those who were targeted by the peer messenger program improved their work after undergoing counseling.

Health Policy and Reimbursement

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A federal contractor who is working to correct the problems with Healthcare.gov said Nov. 4 that while some repairs to the site have been completed, there will still be recurring outages in the weeks ahead. The contractor, who spoke on background during a conference call with reporters, said such outages are the result of an increasing amount of volume on the system as repairs are being made and are a "natural part" of the effort to correct the problems with the site. The contractor added that several issues related to the processing of the 834 forms that the system sends to insurers to verify that a consumer has enrolled in a plan have been successfully completed. However, the contractor said that more work needs to be done to ensure that the information about enrollees that is included in the forms is accurate. Also speaking during the conference call was Centers for Medicare & Medicaid Services (CMS) spokeswoman Julie Bataille, who said that Healthcare.gov should be fixed by the end of the month. Bataille also said that the roughly 90-minute outage that took place on Nov. 4 was not related to two previous outages last month that were caused by a network failure at a data center that hosts Healthcare.gov.


There are growing calls from lawmakers of both parties to at least temporarily roll back some of the provisions of the Affordable Care Act (ACA) in response to the problems with Healthcare.gov, which have made it difficult for many consumers to sign up for health insurance coverage through the federal exchange. For instance, Sen. Mary Landrieu (D-La.) is expected to propose a bill that would allow consumers to keep their existing plans even if they do not meet ACA's standards. The ACA's individual mandate is under fire as well, with Sen. Marco Rubio (R-Fla.) recently introducing legislation that would delay the implementation of the mandate until six months after the Government Accountability Office certifies that Healthcare.gov is completely functional. Administration officials have promised that the site will be working smoothly by the middle of this month. The prospects for a delay in the mandate are uncertain. Healthcare lobbyist Julius Hobson said he believes that the political pressure to delay the mandate is currently not strong enough to bring about such a change, though he said that the pressure could ratchet up even more if the administration fails to fix the problems with Healthcare.gov by mid-November as promised.


Senate Finance Committee Chairman Max Baucus (D-Mont.) and House Ways and Means Committee Chairman Dave Camp (R-Mich.) have introduced a draft proposal that would permanently repeal the Medicare sustainable growth-rate formula (SGR) and reform the fee-for-service system. The proposal calls for no changes to current physician payment levels between now and 2023, though doctors who participate in accountable care organizations and other alternative payment models would subsequently receive annual payment increases of 2 percent. Others would receive a 1 percent increase. The proposal also creates new payment codes for care-management services for patients with complex care needs in order to encourage the use of these services. In addition, the draft calls for the use of standard-of-care guidelines developed by doctors to avoid the unnecessary provision of services. However, one major obstacle to getting the proposal passed exists: it does not include any suggestions for how to pay for the repeal of SGR. Agreeing to a way to pay for the repeal of SGR is an obstacle because it could create financial pain for some healthcare industry groups. Nevertheless, the American Medical Association and other healthcare organizations have expressed cautious optimism about the proposal.


Documents obtained by CBS News indicate that the pace of consumer enrollment in health insurance policies offered through Healthcare.gov was very slow immediately after the site went live. Notes from the so-called "war room" meetings at the Centers for Medicare and Medicaid Services state that only six enrollments had occurred nationwide as of the morning of Oct. 2, the day after the federal health insurance exchange was rolled out. That number climbed to roughly 100 by that afternoon and 248 by the end of the day. The notes also discuss some of the problems that Healthcare.gov was experiencing at that time, including consumers' inability to directly sign up for plans on the Web sites of insurance companies participating in the exchange, as well as confusion surrounding credit check information that was blamed on the credit reporting agency Experian. Obama administration officials have recently said they could not or would not provide enrollment figures, though the notes say that such information was continuously being made available. A spokesman for the Department of Health and Human Services said that the enrollment figures in the notes may not include consumers who enrolled with paper applications or other methods besides the Web site.


Health and Human Services (HHS) Secretary Kathleen Sebelius appeared before the House Energy and Commerce Committee on Oct. 30 and told lawmakers that the problems with the federal health insurance marketplace Healthcare.gov have made it impossible to accurately determine how many consumers have used the site to purchase health insurance. However, Sebelius said that she expects to know by mid-November how many consumers have signed up for health insurance through Healthcare.gov. Sebelius also addressed the problems with Healthcare.gov during her testimony, taking responsibility for the issues and pledging to fix the problems so that the site is running smoothly by mid-November. One of the problems that has priority, Sebelius said, is the issue with the 834 document, which contains the name of a person purchasing health insurance coverage through the exchange and is sent to an insurer so that the company can verify the information. That system is currently not working, Sebelius said. Sebelius also addressed questions from Republicans who said that some of their constituents are having their health insurance plans cancelled by their insurers, even though President Obama has said that the Affordable Care Act (ACA) would not force anyone to change their plan. The secretary said that ACA regulations do not apply to plans that were in effect in March 2010 unless the insurer makes changes that reduce benefits and add costs for the insured.


The Obama administration is facing growing calls from lawmakers to delay the implementation of the Affordable Care Act's individual mandate due to the ongoing problems with Healthcare.gov, the federal health insurance exchange. Sen. Marco Rubio (R-Fla.) and Rep. Trey Radel (R-Fla.) have introduced a bill that would delay implementation of the penalty for failing to comply with the individual mandate until six months after the Government Accountability Office certifies that Healthcare.gov is working effectively. Sen. Joe Manchin (D-W.Va.) has called for the individual mandate to be delayed by a year, while 10 other Democratic senators have called for the open enrollment period to be extended beyond March 31. But American Enterprise Institute healthcare analyst Thomas Miller says that the Obama administration is not likely to approve any significant changes to the Affordable Care Act out of fear that doing so will only open the door to even more alterations. Meanwhile, some healthcare industry observers are expressing concern that any delay in the individual mandate will have a negative effect on insurers offering plans through the exchanges, since the pool of covered consumers could initially consist more of expensive sicker consumers than the healthier individuals who are needed to offset the costs of insuring their more expensive counterparts.

Medicine, Drugs and Devices

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A study published in the journal Diabetes Care has concluded that patients with diabetic foot osteomyelitis and ulcers in the forefoot should be treated with antibiotics first before surgery is considered. The study by researchers in Spain randomized 52 patients with diabetes and foot osteomyelitis to one of two treatment groups: one in which patients were treated with antibiotics such as trimethoprim, ciprofloxacin, and tetracycline for 90 days; and another in which patients underwent surgery followed by 10 days of antibiotic treatment. Researchers examined the patients after 12 weeks and found that 75 percent of those in the antibiotic group had achieved primary healing, compared to 86.3 percent in the surgery group. The difference was not significant. The median time to healing was six weeks in the antibiotic group and seven weeks in the surgery group. Researchers also found that four patients who were treated with antibiotics experienced a worsening of their condition and had to be operated on, while three patients in the surgery group required an additional operation. The rate of minor amputations in the two groups was the same. Lead author José Luis Lázaro-Marinez, PhD, of the Unidad de Pie Diabético said the findings indicate that a 90-day antibiotic regimen is the best option for patients who have an osteomyelitis-related soft-tissue infection, and that surgery can be considered if such treatment is ineffective.


A new study has found that patients who undergo total ankle arthroplasty (TAA) using the Salto fixed bearing total ankle prosthesis experience significant improvements in subjective outcome measures and range of motion. Researchers retrospectively reviewed the radiographs and patient records of 74 consecutive patients with 75 TAA implants, and found that total ankle survivorship was 98 percent after an average follow-up period of 43 months. No ankles were converted to an arthrodesis, though there was one deep infection. Average dorsiflexion, meanwhile, improved from 4.3 ± 3.3 to 8.7 ± 5.6 degrees. Average ankle plantarflexion improved as well, moving from 24 ± 11 to 29 ± 7 degrees. Significant improvements were also seen in all subscales of the Foot and Ankle Outcome Score (FAOS). Researchers also observed a significant improvement in the physical component of the Short Form-12 (SF-12), which rose from 30 ± 8 to 41 ± 13. The mean Visual Analog Score for patient satisfaction was nine. Two patients had component migration, one tibial and one talar component, though a revision procedure was not necessary in either of these cases. Six ankles had a total of nine radiolucent lines with a radiographically stable implant. No patients experienced cystic changes.