News From ACFAS

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Looking for exceptional, practical education? You won't need to look far to find some great programs right in your own backyard! ACFAS is proud to once again bring the education to YOU with its Advanced Forefoot Reconstruction and Complications Workshops and Seminars – a series of six hands-on programs, taking place across the nation, for practicing and in-training surgeons to advance their forefoot surgical skills.

Offered as a partnership between ACFAS and six ACFAS Divisions, this ACFAS Coming to You program begins on a Friday evening with the first of multiple presentations on “Common Forefoot Surgical Complications – How to Deal with Them,” followed by a discussion of case studies from participants. Saturday provides a full-day of hands-on workshops, lectures and panel discussions to review problematic cases.

Don’t miss out on this valuable opportunity -- find the city closest to you and register today at acfas.org/comingtoyou. Program locations and dates include:

2014
Spokane, Washington
September 19-20, 2014
Division 2

State College, PA
October 3-4, 2014
Division 12

Salt Lake City, UT
November 14-15, 2014
Division 4

Columbus, OH
December 5-6, 2014
Division 13

2015
Buffalo, NY
April 17-18, 2015
Division 10

Portsmouth, NH
May 1-2, 2015
Division 8

For a view of the full brochure, visit acfas.org/comingtoyou. In order to support those unmatched residents who have yet to find a placement within a program, the ACFAS Membership Committee has created a new “Student-Transitional” category of membership and offers graduated students a one-year complimentary transitional membership. In previous years, those who remained unmatched were not provided access to ACFAS member benefits until they found a match and were able to join as a resident.

Graduated students who are without a residency match can benefit from association with ACFAS, through electronic access to the Journal of Foot & Ankle Surgery, student pricing to all ACFAS educational offerings, and linkage to a network of proven leaders who can be available to them in their search for a match. The one-year complimentary transitional membership allows them to stay as part of the ACFAS community, receive the many benefits of membership for the next 12 months, keep this professional society on their résumé, and hopefully help them to bridge the gap to finding a placement in the next 12 months.

If you are an unmatched residency placement or know of someone who could benefit from this transitional status with ACFAS, please contact the Membership Department at (773) 693-9300 or via email at membership@acfas.org for more information and assistance.

Foot and Ankle Surgery

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A recent study sought to quantify the origins and insertions of lateral ligaments related to surgically pertinent osseous landmarks in order to help surgeons who perform anatomic repair or ankle reconstruction to treat lateral ankle sprains. Researchers dissected 14 ankle specimens to isolate four lateral ligaments and then used a measuring device to determine the origins, insertions, footprint areas, orientations, and distances from osseous landmarks. Single-banded anterior talofibular ligaments, which were seen in half of the specimens, originated an average of 13.8 mm from the inferior tip of the lateral malleolus at the anterior fibular border and were inserted an average of 17.8 mm superior to the apex of the lateral talar process along the anterior border of the talar lateral articular facet. Researchers found that the calcaneofibular ligament originated an average of 5.3 mm from the inferior tip of the lateral malleolus at the anterior fibular border and were inserted an average of 16.3 mm from the peroneal tubercle's posterior point. As for the posterior talofibular ligament, it originated an average of 4.8 mm superior to the inferior tip of the lateral malleolus in the digital fossa and was inserted an average of 13.2 mm from the talar posterolateral tubercle. Finally, researchers found that the cervical ligament originated at the superior point of the calcaneus and was inserted at a point located at roughly half of the talar neck anteroposterior distance.


A new study examined the effectiveness of using a percutaneous technique to correct persistent severe metatarsus adductus (MA) deformities in children, a type of treatment that has been inadequately studied despite its growing use in correcting foot deformities in adults. The study involved 34 consecutive feet with severe, rigid MA deformities that were treated by taking a percutaneous approach to the Calhuzac procedure for MA correction. The study found that the use of this technique was successful in correcting the MA deformities. All of the childrens' feet had a normal heel bisector line at final follow-up, which was performed an average of 55.2 months after the procedure. Average American Orthopaedic Foot and Ankle Society (AOFAS) scores, meanwhile, improved from 78 before surgery to 98 afterward. The average surgical and hospitalization times for patients were 14 minutes and six hours, respectively, both of which were significantly lower than what is observed in patients undergoing other types of treatment. Finally, the study noted that the percutaneous approach was minimally invasive and brought about better cosmetic results than other procedures.

Practice Management

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The delay in the implementation of ICD-10 until Oct. 1, 2015 gives physicians' practices time to address a number of issues to ensure that they are ready for the switchover. One issue that most practices may have to address is the coordination that takes place with referral partners. Experts say practices need to be sure that their referral partners, particularly those that provide them with a large number of referrals or high-value referrals, are also ready for the transition to ICD-10 by assessing the accuracy and thoroughness of the codes that they are currently providing. In addition, experts say that practices that are not as ready for the switchover to ICD-10 as they should be may want to consider establishing formal ICD-10 transition committees to handle issues such as training staff on the new codes, revising the electronic health record (EHR) and paper forms to ensure that they are ICD-10 compliant, and ensuring effective communications with referral partners, payers, and hospitals. Using such formal committees to handle these issues may be a better approach than relying on one or two practice staff members to deal with them, says PricewaterhouseCoopers ICD-10 leader John Dugan. Finally, experts say that practices should be prepared to use both ICD-9 and ICD-10 codes for a time by providing practice staff members with resources that help them identify the ICD-10 codes that correlate with their most commonly-used ICD-9 codes.


The time-saving tools that are included in electronic health record (EHR) systems to make documenting patient records easier should be used carefully, since practitioners who carelessly use these tools may improperly bill payers and patients, writes medical billing and coding consultant Renee Dowling. One such tool that practitioners should use with caution is the copy-and-paste feature, which allows users to copy information from a provider's note or other sources into a patient's EHR. Practice staff members who use this tool should be sure to update the information they are copying and pasting, if necessary, and verify that it is accurate. Failing to do so can result in a patient's EHR containing inaccurate information, which in turn can result in the patient and/or the relevant payer being billed for an incorrect sum. Physicians' practices should also be aware that the copy-and-paste tool can be used maliciously to create fraudulent claims. Another tool that Dowling says should be carefully used is one that can automatically create extensive documentation containing patient information. Doctors should also be sure to review such documentation for accuracy, since this tool can produce information indicating that a practitioner performed more comprehensive services than were billed.

Health Policy and Reimbursement

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Economists are divided over what if anything the Commerce Department's final estimate of first quarter healthcare spending illustrates about the impact that the implementation of the Affordable Care Act (ACA) is having on the nation's healthcare system. The department's Bureau of Economic Analysis (BEA) estimated annualized healthcare spending in the first quarter and compared it with spending in the fourth quarter of 2013, and concluded that healthcare spending will drop 1.4 percent this year. Economist Ian Shepherdson says the final estimate from BEA dispels the notion that the implementation of ACA sparked a significant increase in healthcare spending. But other economists have been more circumspect in their assessments of BEA's estimate, saying that data taken from a single quarter may not be the best indicator of spending trends over a longer period of time. Others, including economist Charles Roehrig, say that ACA may yet spark an increase in healthcare spending. Roehrig points out that such an increase may not be evident until BEA analyzes data from the second quarter, which will include spending on doctors and hospital visits by people who have gained insurance coverage under ACA. Economists Jonathan Skinner agrees, saying that healthcare spending is likely to increase 1.2 percent faster than the nation's gross domestic product.


Sens. Dianne Feinstein (D-Calif.) and Chuck Grassley (R-Iowa) sent a letter to Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner on June 24 in which they said that the surveys that are carried out as part of CMS' value-based purchasing program are encouraging doctors to improperly prescribe addictive pain medications. The survey the senators were referring to is the Hospital Consumer Assessment of Healthcare Providers and Systems Survey, which asks hospital patients whether they needed drugs for any pain they experienced during their hospital stays, how often that pain was well-controlled, and how often hospital staff did everything possible to help minimize that pain. The answers to these surveys are used to determine Medicare payments to hospitals. But Feinstein and Grassley say they have evidence that some doctors are improperly prescribing painkillers in order to increase their scores on these surveys and boost Medicare payments made to the hospitals where they work. The letter cites at least two incidents that the senators said is evidence of the problem, including one in which a woman went to the emergency room for a toothache and was given a prescription for Dilaudid. The letter also asked Tavenner to provide information about what CMS is doing to address the effect the surveys are having on the improper prescription of painkillers. CMS has not commented on the matter.


The Centers for Medicare and Medicaid Services (CMS) is gearing up to implement a controversial new system that would penalize hospitals with the highest rates of infections and patient injuries--an effort that CMS says is designed to improve patient safety but one that some hospitals feel is unfair. The program, which will be launched in October, calls for CMS to examine three metrics of hospital-acquired conditions: the frequency of bloodstream infections in patients who had catheters inserted into a major artery in order to deliver treatments or nutrients; the rate of infections in patients who need urinary catheters; and the rate of other avoidable health problems some patients can experience during a hospital stay, including accidentally punctured lungs, blood clots, and hip fractures. Hospitals with the worst performances on these metrics will lose 1 percent of their Medicare payments a year as a penalty. A preliminary analysis indicates that 761 hospitals would be penalized under this system if it was in place now. CMS' Dr. Patrick Conway says the new program will encourage hospitals to focus on patient safety and on eliminating harm to patients, though some hospital officials believe it will unfairly penalize facilities that are trying to be vigilant in identifying potential patient safety problems because these providers will have high rates of hospital-acquired conditions. Others say that the penalties will disproportionately affect some hospitals, including those that serve the poor and those in urban areas, though CMS says it takes these and other factors into account when determining infection rates.


The Pennsylvania state Senate is set to take up a bill that proponents say could help prevent a shortage of suppliers and specialists who provide prosthetic devices or corrective footwear. The bill, which has already been approved by the state House, amends an existing law that required prosthetists, pedorthists, orthotists, and orthotic fitters in Pennsylvania to meet licensing requirements by July 6 but did not allow certified specialists to continue practicing while they waited to obtain those licenses. The amendment being considered will also ease some planned work-experience requirements for these providers and allow pharmacies and other suppliers to continue to sell specialized shoes for diabetics. Pennsylvania Orthotic and Prosthetic Society President Eileen Levis says failing to pass the amendment could force hundreds of specialists to stop working for a time.

Medicine, Drugs and Devices

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Administering tofacitinib as a monotherapy may be better than using methotrexate to treat some patients with rheumatoid arthritis (RA), a new study has found. The 958 rheumatoid arthritis patients who participated in the study, all of whom had never been given methotrexate or therapeutic doses of the treatment, were divided into two groups: one that was given a 5 mg or 10 mg dose of tofacitinib twice a day, and another that was given a dose of methotrexate that was gradually increased to 20 mg per week over eight weeks. Only 12 percent of patients in the methotrexate group achieved American College of Rheumatology (ACR) 70 response after six months, which was a 70 percent or greater reduction in the number of tender and swollen joints and a 70 percent or larger improvement in three of the following criteria: pain as perceived by the patient, level of disability, C-reactive protein level or erythrocyte sedimentation rate, global assessment of disease by the patient, and global assessment of the disease by a physician. By comparison, 25.5 percent of patients given a 5 mg dose of tofacitinib and 37.7 percent of those given a 10 mg dose achieved ACR70 after six months. Researchers noted that while their findings indicate that tofacitinib is superior to methotrexate in reducing RA signs and symptoms and slowing the progression of structural joint damage, these benefits need to be considered against the possibility of a number of adverse events seen in patients treated with tofacitinib, including cancer and increased low-density lipoprotein cholesterol levels.


A recent study examined follow-up data on 507 active rheumatoid arthritis patients who were refractory to methotrexate and were treated with infliximab (IFX) as part of the Belgian Extended Access Program. Among the data points that were examined was long-term disease control, which was found to be good in the 110 patients who continued to receive maintenance IFX treatment after 10 years of followup. The study found that the average 28-joint Disease Activity Score (DAS28) in these patients was 2.55 +/- 1.01. However, the study also found that of 16 of the 160 patients who were treated with IFX for seven to 10 years were lost to followup while 34 ended treatment primarily because of a loss of efficacy. Finally, the study examined the baseline characteristics of patients who successfully completed IFX treatment for 10 years, finding that these individuals had lower baseline values for DAS28, patient pain scale, physician visual analog scale, and the Health Assessment Questionnaire compared to other patients who did not complete treatment.