News From ACFAS

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On Monday, ACFAS eligible voting members received an email from the College’s independent election firm with a unique link to the 2017 Board of Directors Election website. If you are a Fellow, Associate, Life or Emeritus member, please take a few minutes to cast your vote for your elected leadership. Your vote is important to advancing our profession and surgical specialty.

If you have not yet voted, two more reminder emails will be sent to you in the next few weeks. If you do not have a valid email address on file with the College, watch your U.S. mail for voting instructions. Voting remains open until December 30. Gain a new perspective on your patient cases from specialists in radiology, health technology, pain management and more during the 75^th Anniversary Scientific Conference at The Mirage in Las Vegas, February 27–March 2. Keynote speaker Roni Zeiger, MD, CEO of Smart Patients and former chief health strategist at Google, will kick off the show on February 27 with Collaboration Is Sexy, an insightful discussion on comprehensive patient care. Then over the next three days, grab a front-row seat at compelling sessions, such as:

The Second Victim: The Effect of Medical Errors on Healthcare Providers
Patrice M. Weiss, MD

Opioid Dependency/Chronic Pain Patient
Alberto E. Ardon, MD

Radiology of Acute vs. Chronic Charcot vs. Infection
Glenn M. Garcia, MD

Combined Medial Column Fusion: Decision Making and Fixation Methods
Thomas G. Harris, MD

What’s on the Horizon? Emerging Technologies
Troy S. Watson, MD

Download the ACFAS 75 conference program at acfas.org/vegas for a complete listing of all sessions and speakers. Do you participate in the Medicare and Medicaid Electronic Health Record (EHR) Incentive Programs? The U.S. Centers for Medicare and Medicaid Services published a final rule on October 16, 2015 that specifies criteria eligible professionals, eligible hospitals and critical access hospitals must meet to participate in the incentive programs. The final rule’s provisions encompass the definition of meaningful use for 2015 through 2017. View the 2016 Tipsheet for eligible professionals at cms.gov. Give your end-of-the-year practice marketing efforts a boost with the latest issue of FootNotes, our free patient education newsletter. Download Winter FootNotes from the ACFAS Marketing Toolbox and distribute copies of it to your patients or post it on your practice's website and social media outlets. Customize page 2 of FootNotes with your practice’s contact information for maximum reach.

Articles in Winter FootNotes include:

• Five Tips for Healthy Holiday Feet
• Snowboarders: Be Sensible on the Slopes
• Do a Midyear Performance Check on Your Children’s Feet

Visit acfas.org/marketing for many other free resources, such as infographics and PowerPoint presentations, to promote your practice in the new year.

Foot and Ankle Surgery

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A study aimed to determine the accuracy and reproducibility of implant position with patient-specific guides for total ankle arthroplasty. Forty-four patients undergoing total ankle arthroplasty received a total ankle implant using PROPHECY patient-specific guides. Preoperative computed tomography scans were used to assess coronal plane deformity, assess mechanical and anatomic alignment and build patient-specific guides. The mean preoperative coronal deformity was 4.6 degrees. In nearly 80 percent of patients, the postoperative implant position of the tibia corresponded with the preoperative plan within three degrees of the target. The implant position corresponded with the preoperative plan within four degrees in 88.6 percent of patients and within five degrees in 100 percent of patients. The tibial component coronal size was correctly predicted in 98 percent of cases, and the talar component was correctly predicted in 80 percent of cases.


A consensus has not been reached regarding the optimal surgical treatment for chronic lateral ankle instability with subfibular ossicle, so researchers evaluated the clinical and radiographic outcomes of the modified Broström procedure with subfibular ossicle excision. The study cohort consisted of 96 patients treated with the modified Broström procedure using bone tunnel and suture anchor techniques. The 96 ankles were divided into two groups: the ossicle group (42 ankles) and nonossicle group (54 ankles). Mean Karlsson scores improved from 55.2 to 95.3 in the ossicle group and from 56.4 to 94.8 in the nonossicle group after a mean follow-up duration of 63.7 months and 62.1 months, respectively. Mean American Orthopaedic Foot and Ankle Society (AOFAS) ankle-hindfoot scores also improved from 63.3 to 95.9 in the ossicle group and from 62.8 to 95.1 in the nonossicle group. The mean talar tilt angles were 7.6 degrees in the ossicle group and 6.8 degrees in the nonossicle group at the final follow-up. Mean anterior talar translations in the ossicle and nonossicle groups improved from 9.3 millimeters and 9.4 mm preoperatively to 5.9 mm and 5.7 mm at final follow-up, respectively.


A study aimed to assess patient outcomes following conservative resection and radiotherapy (RT) for soft-tissue sarcoma (STS) of the distal extremity. The study included 33 patients with STS involving the hand/wrist or foot-ankle complex who received adjuvant RT with conservative resection. Eight patients were treated with preoperative RT, and 25 were treated with postoperative RT. Patients were evaluated for local tumor control, survival, toxicities and preservation of objective functional ability. Adverse events related to gait, limb edema, skin infection, wound complications and wound dehiscence were also assessed using the Common Terminology Criteria for Adverse Events. The five- and 10-year local control rates were 90 percent. The 10-year cause-specific, absolute and distant metastasis-free survival rates were 97 percent, 87 percent and 84 percent, respectively. Three patients underwent amputation for reasons other than local recurrence or treatment complications. Scores on the Toronto Extremity Salvage Score ranged from 88 to 100 with a mean of 98.2. One patient had a grade three skin infection and one experienced a grade two wound complication of dehiscence.

Practice Management

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Although many physicians are confident in their ability to manage their finances, few are prepared to navigate financial planning successfully without the help of a professional, according to Joel Greenwald, a former internal medicine physician and certified financial planner (CFP). When selecting a financial adviser, physicians should be aware of the many designations and certifications in the field. Experts recommend that physicians seek four types of advisers: a CFP, Chartered Financial Analyst, Chartered Financial Consultant or a Certified Public Accountant with a Personal Financial Specialist designation. Physicians should select candidates who are also fiduciaries or who would be willing to sign the fiduciary pledge, stating that they will put the interest of their clients first. After reviewing an adviser’s credentials, physicians should identify how the adviser gets paid and whether the fees are one-time, ongoing or if they increase over time. Financial advisers can be paid commissions by investment companies, charge asset management fees or take fees out of assets. Additionally, Greenwald says it is important to work with advisers who already understand the specialized issues faced by medical professionals. “You don't want your adviser learning from you about the special needs of physicians,” Greenwald says. “The adviser doesn't have to specialize only in working with medical professionals, but ask them who are the clients they work with.”


Cloud-based healthcare applications can present a number of significant advantages for practices and physicians. Cloud solutions can be financially beneficial for practices with limited budgets, as many cloud services are subscription-based models with minimal upfront costs. Physicians and staff are able to offload much of their information technology operations to their cloud vendors, improving efficiency and responsiveness. Recovery of lost files can also be a potentially less expensive process; patient records stored on a remote server are more likely to be recovered than data kept on an in-office computer or server. Another important feature of the cloud is the availability of data, which can expedite decision-making and improve continuity of care. The cloud enables patient records and time-sensitive information to be available instantly and assists other providers involved in the patient’s care. "The ability to connect with outside resource labs, hospitals, imagery and a patient’s medication history and to access other providers who treat the patient allows us to manage our patients immediately and more effectively, with the complete knowledge and patient history in real time," says pediatrician Peter Masucci. Furthermore, cloud-based portals give patients more immediate access to their health information and to their care team.

Health Policy and Reimbursement

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Republican lawmakers and President-Elect Donald Trump may eventually find it irresponsible to move forward with a complete and immediate repeal of the Affordable Care Act (ACA). Although some of the law’s most contentious components could be replaced, sections detailing Medicare reforms, workforce provisions, Medicaid program refinements, biosimilar pathways and hundreds of other items may be kept or slightly altered. A repeal of the insurance mandate would also take away a critical mass of healthy enrollees, leading to steep premium hikes and collapsing markets. Republicans have discussed delaying repeal until a complete replacement is passed, but lawmakers on both sides of the aisle would be reluctant to agree to an approach that leaves some of their constituents without coverage. The most prominent proposal to replace the ACA has been House Speaker Paul Ryan’s plan, “A Better Way.” However, the plan still lacks legislative language and a Congressional Budget Office cost assessment, and it is unclear how many Republicans will support Ryan’s proposal to institute hundreds of billions of dollars’ worth of new tax credits for coverage resembling the ACA.


A federal appeals court has brought to an end President Barack Obama's bid to overturn a ruling that threatens to gut his signature healthcare law by putting the case on hold until after President-Elect Donald Trump takes office. The Obama administration had appealed a judge's May ruling favoring the challenge filed by Republicans in the U.S. House of Representatives against a key part of the Affordable Care Act. The Obama administration appealed U.S. District Judge Rosemary Collyer's ruling that the government cannot spend billions of dollars in federal funds without congressional approval to provide subsidies under the healthcare law to private insurers to help people afford medical coverage. However, the U.S. Court of Appeals for the District of Columbia Circuit agreed to a request by Republicans to delay its consideration of the government's appeal until after Trump takes office in January.


Reviewing electronic health record (EHR) contingency plans and wireless penetration tests of some U.S. Centers for Medicare and Medicaid Services (CMS) data centers were areas of focus this past reporting period, according to the U.S. Office of Inspector General’s (OIG) semiannual report to Congress. Over the summer, OIG announced that almost all surveyed hospitals have written EHR contingency plans in case of a natural disaster, cyberattack or other emergency. In an investigation of CMS’ wireless network security controls, OIG identified four vulnerabilities at certain CMS data centers. According to the report’s authors, the vulnerabilities could have resulted in unauthorized access to personally identifiable information and disruptions of critical operations. During the reporting period, OIG issued reports recommending CMS improve Medicare and Medicaid provider data systems. The most recent report also discusses the efforts of Healthcare Fraud Strike Force units within the Healthcare Fraud Prevention and Enforcement Action Team, assessments of home- and community-based services and common characteristics in home health fraud cases.


Industry trade group America's Health Insurance Plans has detailed what parts of the Affordable Care Act (ACA) they want to stay in state marketplaces. Among the demands are a commitment from Donald Trump and Congress that the government will continue to offset some costs for low-income Americans. Insurers also want rules that encourage young and healthy people to sign up to remain in place. The threat of repeal of the ACA comes as experts say state marketplaces are already facing financial uncertainty. Health insurers have signaled they will not fight repeal of the law, but they do not want to rush the process. Meanwhile, Republicans are discussing ways to stabilize the marketplaces and are trying to reach a consensus on what an ACA replacement will look like.


The American Hospital Association and the Federation of American Hospitals sent a letter to President-Elect Donald Trump and Congress warning that the repeal of the Affordable Care Act could cost hospitals $165 billion in 10 years. In addition, repeal of the law would cause "an unprecedented public health crisis." Trump has said he would repeal the law if elected, and Republicans have been staunch critics of the law. A study by the Congressional Budget Office found that removing the law would leave an additional 22 million people without insurance by 2026.

Medicine, Drugs and Devices

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The Senate passed the 21^st Century Cures bill, which is aimed at expediting U.S. Food and Drug Administration (FDA) approval processes for drugs and medical devices. Under the bill, certain drugs could see shorter trials and gain additional approvals for new uses based on relatively little evidence. The measure will also allow wider use of surrogate endpoints in medical studies. The White House has signaled its support for simpler FDA trial designs, and President Barack Obama said after the Senate vote he would sign the measure immediately. President-Elect Donald Trump, who has discussed scaling back FDA regulations, is expected to embrace the approach laid out in the bill. Some medical experts and consumer advocates are concerned that nonconventional approval methods could weaken drug and device safety standards. “Industry will be emboldened by this legislation, and under a deregulation-minded commissioner, will seek further changes in the FDA regulatory scheme,” says Michael Carome, director of the Public Citizen Health Research Group. Supporters, such as PhRMA and AdvaMed, praise the bill as a way to drive innovation and improve patient access to new medications.


The 21^st Century Cures bill passed by the House provides clarification on the regulation of medical software. The legislation, which now heads to the Senate for consideration, identifies five specific categories of medical software that—given certain conditions—will not be regulated as a medical device by the U.S. Food and Drug Administration based on their low level of risk to patients. The five categories of medical software include: administrative and operational, such as appointment software; wellness, such as apps for tracking exercise; electronic health records; software for transferring, storing or displaying medical device data, such as lab data; and clinical decision support software.