News From ACFAS

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If you need CME before the end of year, visit acfas.org/e-Learning to:

• view Clinical Session videos of actual lectures from the most respected members of the DPM community
• purchase the Arthroscopy of the Foot & Ankle e-Book
• purchase the entire Surgical Techniques series on DVD

Each tool in our e-Learning portal includes an exam—pass it and submit it to ACFAS to obtain your continuing education contact hours. And since our e-Learning portal is accessible anytime from anywhere, you can earn CME when it’s convenient for you.

Prefer to earn CME live and in person? Register for the Refining High-Frequency Forefoot Surgery Workshop and Seminar, December 2–3 in Phoenix or attend our 75^th Anniversary Scientific Conference, February 27–March 2 in Las Vegas. Look for the HUB in a new location outside the Exhibit Hall during the 75^th Anniversary Scientific Conference at The Mirage in Las Vegas. The HUB is your place to learn the “whys” behind what experts do and to benefit from their inside story—what each presenter wants you to know about a top-of-mind issue.

Visit the HUB from February 27 through March 1 to hear 50-minute presentations on digital marketing for your practice, contract negotiations, MACRA, workplace politics and more. The HUB comfortably seats 45 people and is known for generating rousing discussion that lasts long after the conference concludes.

Download the ACFAS 75 program at acfas.org/vegas to see the latest HUB schedule, which continues to morph and change, and decide which sessions you’d like to attend. No preregistration is necessary. Have you visited the U.S. Centers for Medicare and Medicaid Services' (CMS) Quality Payment Program website? It contains information on the new quality payment programs that CMS hopes will improve Medicare. Under the quality payment program, you, as the foot and ankle surgeon, can choose how to participate based on your practice size, specialty, location or patient population.

Many of you will participate in the Merit-Based Incentive Payment System (MIPS). CMS has created a tool for you to browse the different MIPS measures and activities. Familiarize yourself with these measures and work with your office staff to identify those that best fit your practice and patient population.

Questions? Contact Sarah Nichelson, JD, ACFAS director of Health Policy, Practice Management and Research. The U.S. Bone and Joint Initiative is seeking young investigators to apply for the Young Investigators Grant Mentoring and Career Development Program in musculoskeletal diseases within the United States. This workshop provides promising junior faculty, senior fellows or postdoctoral researchers who have been nominated by their department or division chairs the opportunity to receive top-notch mentorship in research, funding and academia. The deadline to apply is January 15, 2017. Visit usbji.org for more information.

Foot and Ankle Surgery

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Continuous regional anesthesia for foot surgery outpatients is effective, but the healthcare costs associated with the perioperative process have been unclear. The study consisted of 120 patients allocated in the day-care or in-patient group. Standardized continuous popliteal sciatic nerve block was performed in both groups for 48 hours using an elastomeric pump delivering ropivacaine 0.2 percent at a rate of 5 milliliters per hour with an additional 5 ml bolus every hour. Outpatients were discharged the day of the surgery. Total management costs were significantly reduced in the day-care group, with no difference between the groups regarding pain at rest and in motion, pain after catheter removal and postoperative nausea and vomiting. Persistent motor block and catheter inflammation were comparable in the two groups. There was no difference in the number of unscheduled ambulatory visits or readmissions.


B-mode ultrasound and elastography indicate that smoking can adversely affect the patellar and Achilles tendons, according to a study published in the Journal of Ultrasound in Medicine. Scans of 69 healthy volunteers determined smokers had thinner patellar and Achilles tendons than nonsmokers. Moreover, the smoking cohort also had significantly lower strain ratio measurements than those in the nonsmoking cohort, which meant the tendons were stiffer. The researchers also found weak negative correlations between the amount of smoking and patellar tendon thicknesses, as well as strain ratio measurements relating to the patellar tendon and the proximal third of the Achilles tendon.


Researchers investigated the feasibility of treating severe open Lisfranc injuries by using one-stage internal fixation with k-wires assocated with vacuum sealing drainage. The study included 20 cases of open Lisfranc joint fracture-dislocation. The American Orthopaedic Foot and Ankle Society midfoot scores were 69.2 at six months after surgery and 78.2 at 12 months. The average visual analogue scale scores at six months and 12 months after surgery were 4.3 and 1.3, respectively. The average time of internal fixation surgery was 47 minutes. There were three cases of wound-edge necrosis, but there were no cases of skin necrosis around the incision. The mean hospital stay was 16.1 days.

Practice Management

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The cost of doing business for medical practices continues to rise as personal incomes stay the same or decrease, according to the 2016 Physicians Practice Physician Compensation Survey. About 40 percent of survey respondents say their overhead is 41 percent to 60 percent of their medical revenue, up from 32 percent of respondents who cited the same figures last year. To rein in overhead, Fairfield County Medical Group internist Steven Fisher recommends carefully examining profit and loss statements to find redundancies or unnecessary expenses. Fisher’s practice requires all patients with high-deductible plans to keep a credit card on file to ensure expedient payment. If patients do not want to provide their card information, they should be required to pay the estimated amount at the time of service. Charlene K. Mooney of Halley Consulting Group suggests tracking charges from vendors and renegotiating contracts. Practices might also consider leasing equipment instead of purchasing. To avoid costs associated with employee turnover, practices should offer their employees pay and benefits that are competitive with the market. Retaining existing patients and increasing patient volume also can boost practice revenue. Adding advanced practice providers, new services and in-office tests can be new sources of revenue. Finally, it might be beneficial for smaller practices to enter into a contract with a hospital or larger health network for a greater access to clinical resources.


Low-tech violations of patient data occur more frequently than high-tech breaches, and they have the potential to cause harm and sometimes incur serious penalties. Visual hacks can happen when employees leave paper records on a desk or permit a monitor to be casually seen. There are seven simple tips to maintain the confidentiality of patient data, including adoption of an office-wide clean-desk policy. Everyone handling patients' private health information (PHI) should remove papers from their desks and close records on monitors whenever they step away, while papers should be kept in folders when not in use, and files contained in cabinets or drawers. A second tip is to make sure office doors are shut when possible, while a third step involves restricting access to areas with computer monitors or workstations displaying PHI. Also recommended is ensuring systems displaying PHI on monitors have an automatic shutoff feature triggered when there is no activity. In addition, staff should be aware of others close to them when they are working with PHI on a mobile device outside of their regular work environment. Meanwhile, staff should be trained to not be excessively trusting and to be sure anyone requesting access is entitled to it. The final tip is to schedule regular walk-throughs to guarantee proper procedures are followed.


Changes to the healthcare environment have caused the problem of burnout to worsen, with more than half of U.S. physicians reporting at least one symptom of professional burnout in 2014, according to the Mayo Clinic. Additionally, the transition to electronic health records (EHR) has placed more pressure on doctors. Although the EHR was originally touted as a time-saving method to manage data, more documentation to meet regulatory requirements has left physicians with less time to interact with patients. In a study published by the Mayo Clinic Proceedings, doctors who used EHRs and computerized physician order entry (CPOE) were found to have lower levels of work satisfaction and higher rates of burnout due to the amount of time spent on clerical tasks. The study’s co-author, Dr. Colin P. West, believes operational changes to the EHR can help ease physicians' burdens. A recent report by the U.S. National Institute of Standards and Technology recommends EHR developers find ways to increase efficiency, such as drafting prepopulated orders and enabling the use of shorthand in documentation. The automation of routine tasks, such as prescription refill requests and previsit planning, could give doctors more time for patient care.

Health Policy and Reimbursement

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President-elect Donald Trump’s healthcare plan, released in March, focuses on seven measures that promise to overturn and replace the Affordable Care Act. Congress also will be urged to eliminate state barriers to allow insurance companies to offer plans in any state. Under the new plan, consumers would be able to deduct insurance premium payments from taxes, and tax-free Health Savings Accounts could be passed on to an individual's heirs without an estate penalty. Trump is pushing for Medicaid to be handled on the state level, including incentives. The president-elect also calls for price transparency from providers and improved access to less expensive drugs.


The U.S. Centers for Medicare and Medicaid Services (CMS) have enlisted the help of expert organizations to assist clinicians preparing to transition to the Merit-Based Incentive Payment System (MIPS). The agency has funneled $700 million in funding to practice transformation networks, which will help clinicians select quality measures and begin transitions to advanced alternative payment models. These networks also are helping practices use electronic health records effectively. An additional $100 million in funding is earmarked for organizations assisting solo, small and rural practices. CMS also hopes to educate healthcare professional organizations and technology vendors in MIPS and the program’s goals. MIPS reporting is slated to begin in January, but CMS will provide a one-year transition period for struggling clinicians. Eligible clinicians will be able to pick their pace and report to MIPS on their own timeline.


New regulations from the Office of the National Coordinator for Health Information Technology (ONC) only require limited testing of electronic health records (EHRs) to check for flaws before the products are installed, and there is no comprehensive system to collect information on safety problems related to the records. The new rule updates the ONC Health IT Certification Program, which establishes regulatory processes for the review of health IT. According to analysis from Pew Charitable Trusts, security gaps in the development and implementation process put patient safety at risk. Pew recommends that ONC take further steps to improve the safety of EHRs by requiring vendors to more thoroughly test EHRs before their products enter the market and after the products have been installed. Second, EHR developers, hospitals, clinicians and other stakeholders should work together to identify safety problems with these records and propose solutions.

Medicine, Drugs and Devices

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Scarf osteotomy has been used in hallux valgus surgery due to its large fixation surface for screws and low risk of complication; however, screw heads may cause skin irritation. The study included 115 patients who had undergone hallux valgus correction with a scarf osteotomy using bioabsorbable screws. Preoperative and postoperative measurements for the intermetatarsal angle (IMA), hallux valgus angle (HVA), distal metatarsal articular angle (DMAA), proximal phalangeal articular angle (PPAA) and lateral translational distance (LTD) were recorded. Preoperative mean values of HVA (32.8 degrees), IMA (14.6 degrees) and PPAA (7.52 degrees) improved at the one-year follow up to 10.7 degrees, 6.0 degrees and 4.6 degrees, respectively. The difference in LTD between follow-ups was not statistically significant. The American Orthopaedic Foot and Ankle Society hallux/forefoot score improved from 69.1 to 96.1. Complications were reported for 16 feet. Of the 16 complications reported, one patient had hardware irritation and one had a foreign body reaction.


Some hospitals have turned to copper installations in patient rooms as a way to kill drug-resistant organisms and reduce healthcare-acquired infections, the costs of which amount to upwards of $96 billion annually in the U.S. Researchers have discovered that copper alloys' sterilizing properties can destroy MRSA, norovirus and other pathogens. To test copper's effectiveness, a hospital in Grinnell, Iowa, outfitted six of the 13 single rooms and three of the five double rooms in its medical-surgical suite with copper bed rails, toilet flush levers, grab bars, soap dispensers, light switches, IV poles and other surfaces. The remaining rooms were left with their original plastic, porcelain and metal surfaces. After terminal cleaning, 88 percent of the bacterial samples from the copper-outfitted rooms fell below recommended contamination levels. Fifty-five percent of samples taken from the rooms without copper exceeded the recommended threshold. Sentara Leigh Hospital in Norfolk, Virginia, also installed copper-infused products in a wing being rebuilt. The new wing had 78 percent fewer healthcare-acquired infections related to multidrug-resistant organisms compared with a baseline period. Infection rates did not change in the old wing.


Although U.S. President-Elect Donald Trump emphasized curbing rising drug prices and repealing the 2.3 percent medical-device tax enacted under the Affordable Care Act in his campaign, drug and device manufacturers are positive his presidency will benefit their industry. Legislation similar to the 21^st Century Cures Act designed to accelerate approvals is more likely to pass under a Republican-controlled Congress and White House. “We are in a new era of medicine with treatments and cures that are completely transforming the fight against debilitating diseases,” says Pharmaceutical Research and Manufacturers of America CEO Steve Ubl. “To ensure this innovation continues, we need to modernize the [U.S. Food and Drug Administration (FDA)] to keep pace with scientific advances, remove regulatory barriers that make it harder to move to a value-driven healthcare system and focus on making better use of the medicines we have today." Drugmakers and devicemakers hope a Trump presidency will be accompanied by a more flexible FDA and a political atmosphere that is “pro-innovation.” Trump's promise to repeal the medical-device tax is good news for the Advanced Medical Technology Association, although its CEO contends the issues at hand have always been “bipartisan issues.”