News From ACFAS

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Showcase your product or service to an audience of more than 1,800 foot and ankle surgeons! Exhibit at ACFAS 2018, March 22–25, 2018 at the Gaylord Opryland Hotel in Nashville.

This year’s Exhibit Hall will span more than 100,000 square feet and will feature unopposed viewing time so you can network with attendees and build new client relationships. As an exhibitor, you may also choose to sponsor an event or educational grant, advertise in ACFAS digital or print media or display your company logo on ACFAS 2018 products.

Watch for your Exhibitor Prospectus in the mail or view it at acfas.org/nashville. Present your latest discoveries in poster format at ACFAS 2018, March 22–25, 2018 at the Gaylord Opryland Hotel in Nashville, and be part of an annual tradition that captures the very best in foot and ankle medical research.

Poster abstracts for this year’s competition must be submitted to ACFAS by October 2, 2017 to be eligible for review. PDFs of eligible posters are due December 15, 2017.

Visit acfas.org/nashville to submit your poster now. Take a New Look at Foot & Ankle Surgeons, the College’s national public relations campaign, is heading to Indianapolis this weekend to exhibit at the American Association of Diabetes Educators’ (AADE) annual meeting. In light of this, ACFAS would like to know if you actively pursue patient referrals from diabetes educators. Vote in this month's new poll at right to share your input.

Visit acfas.org throughout the month to view real-time results, and look for a recap of Take a New Look’s experience at AADE17 in the August 9 issue of This Week @ ACFAS.

Foot and Ankle Surgery

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Diagnosing bone infection in the diabetic foot is challenging and often requires several diagnostic procedures. Researchers compared the diagnostic performances of MRI, radiolabeled white blood cell (WBC) scintigraphy (either with 99mTc-hexamethylpropyleneamineoxime [HMPAO] or 111In-oxine) and [18F]fluorodeoxyglucose positron emission tomography (18F-FDG–PET)/computed tomography. A systematic review was conducted of prospective and retrospective diagnostic studies performed on patients living with diabetes in whom there was a clinical suspicion of osteomyelitis of the foot. The preferred reference standard was bone biopsy and subsequent pathological (or microbiological) examination. A total of 27 full articles and two posters was selected for inclusion in the analysis. The performance characteristics for the 18F-FDG–PET were: sensitivity, 89 percent; specificity, 92 percent; diagnostic odds ratio (DOR), 95; positive likelihood ratio (LR), 11; and negative LR, 0.11. For WBC scan with 111In-oxine, the values were: sensitivity, 92 percent; specificity, 75 percent; DOR, 34; positive LR, 3.6; and negative LR, 0.1. For WBC scan with 99mTc-HMPAO, the values were: sensitivity, 91 percent; specificity, 92 percent; DOR, 118; positive LR, 12; and negative LR, 0.1. Finally, for MRI, the values were: sensitivity, 93 percent; specificity, 75 percent; DOR, 37; positive LR, 3.66 and negative LR, 0.10. The researchers concluded that various modalities have similar sensitivity, but 18F-FDG–PET and 99mTc-HMPAO–labeled WBC scintigraphy offered the highest specificity. Larger prospective studies with a direct comparison among the different imaging techniques are required.


Researchers performed a randomized doubleblind pilot study in 16 healthy volunteers to investigate the success rate for placing a new suture-method catheter for sciatic nerve block. A catheter was inserted into both legs of volunteers, and each was randomly allocated to receive 15 ml lidocaine two percent through the catheter in one leg and 15 ml saline in the other leg. Successful placement of the catheter was defined as a 20 percent decrease in maximum voluntary isometric contraction for dorsiflexion of the ankle. Secondary outcomes were maximum voluntary isometric contraction for plantar flexion at the ankle, surface electromyography and cold sensation. After return of motor and sensory function, volunteers performed standardized physical exercises. Fifteen of 16 initial catheter placements were successful. The reduction in maximum voluntary isometric contraction and surface electromyography affected the peroneal nerve more often than the tibial nerve. Eleven of 15 catheters remained functional with motor and sensory block after physical exercise, and the maximal displacement was five millimeters. Catheters with secondary block failure were displaced between 6 mm and 10 mm. One catheter was displaced 1.8 mm that resulted in a decrease in maximum voluntary isometric contraction of less than 20 percent. After repeat test injection, 14 of the 16 volunteers had loss of cold sensation. The researchers concluded that the suture-method catheter can be placed with a high success rate, but that physical exercise may cause displacement.


Inadequate tendon lengthening is a key problem in the restoration of function following the operative repair of Achilles tendon ruptures. A study was performed to determine differences in initial separation, strength and failure characteristics of differing sutures and numbers of core strands in a percutaneous Achilles tendon repair model in response to initial loading. Researchers repaired 19 bovine Achilles tendons using a percutaneous/minimally invasive technique with a combination of a modified Bunnell suture proximally and a Kessler suture distally. Specimens were then cyclically loaded using phases of 10 cycles of 100 N, 100 cycles of 100 N, 100 cycles of 190 N consistent with early range of motion training and weightbearing, before being loaded to failure. Preconditioning of 10 cycles of 100 N resulted in separations of 4 mm for six-strand, 5.9 mm for four-strand but 11.5 mm in eight-strand repairs. This comprised 48.5, 68.6 and 72.7 percent of the separation that occurred after 100 cycles of 100 N. The tendon separation after the third phase of 100 cycles of 190 N was 17.4 mm for four-strand repairs, 16.6 mm for six-strand repairs and 26.6 mm for eight-strand repairs. The most common mode of failure was pull out of the Kessler suture from the distal stump in 41.7 percent of specimens. The use of a nonabsorbable suture resulted in less end-to-end separation when compared to absorbable sutures when an Achilles tendon repair model was subject to cyclical loading. The effect of early movement and loading on the Achilles tendon is not fully understood and requires more research.

Practice Management

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A key step in curbing ransomware attacks is awareness, such as not clicking on suspicious-looking emails, files or links corrupted with malicious software. Staff should contact IT before clicking on an unfamiliar file or link. Practices should also set up antispam to block suspicious messages, ensure their network firewall is in place and install antivirus software both on the server and at all workstations. Updates and security patches should be installed immediately. In May 2017, a widespread ransomware attack struck more than 150 countries, but security experts note that two months before the disruption, Microsoft had issued a patch for the vulnerability that the malware exploited and updated the protections of its free antivirus software to help shield users. But the affected hospitals had not installed those updates, leaving them vulnerable to the ransomware. The best protection against ransomware is a reliable, continuous backup. Every backup should be tested on a regular basis to verify that it is ready if needed. The IT department also needs to have a restoration protocol in place and to run regular drills to ensure that the disaster recovery plan can be executed immediately if a ransomware attack should occur.


Many physicians are frustrated by the amount of documentation required in electronic health records (EHRs). Just 27 percent of a doctor’s time is spent with patients, and nearly half is spent on EHR and desk work, according to a 2016 study published in Annals of Internal Medicine. Moreover, primary care physicians spend an estimated one to two hours every night after work finishing up their data entry on EHRs, the study found. A smaller study published in April by Health Affairs also found about a 50-50 split in direct patient care time versus desktop medicine. Dr. Albert Chan, a family practice physician and the chief of digital patient experience for Sutter Health Network, points out that doctors are also required to report a series of quality measurements, provide proper insurance coding and introduce more legalistic wording into the EHR to prevent lawsuits. Nevertheless, EHRs can be useful, he says: "You can automatically alert patients about their conditions, for example; you can personalize their care. The lesson I've learned is that the EHR requires work to make it work." Chan forecasts that current design problems, such as the lack of interoperability between EHR systems, can be corrected over time by vendors.


Asset protection plans are as fact-specific as the care provided to patients, although some ideas should be avoided. Estate planning may involve gifts and other asset transfers to heirs or preferred charities, and these holdings usually include legal tools, tax planning and life insurance, which may offer incidental asset protection benefit during one's lifetime. However, for many affluent physicians, a typical estate plan is a will or a revocable living trust (RLT) that actually concerns death planning and ensuring loved ones are provided for and that assets left for their care are managed and distributed efficiently. The revocability of the RLT is intentional and lets physicians set up a trust with specific instructions for what happens and who is in charge after they die and actually put title to assets in it. Full flexibility and the fact that any transfer to the trust is reversible and has no tax implications at the time of transfer is one of the RLT's prime enticements. Moreover, the physician is the grantor of the trust and typically the trustee, and they name successor trustees who serve after them when they are no longer capable or alive. In addition, the property in the trust is still the physician's for all practical purposes because the trust is revocable, and they control the trust and the assets as the trustee and have full discretion to add, remove and transfer trust assets.

Health Policy and Reimbursement

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The Republican effort to dismantle the Affordable Care Act (ACA) collapsed when a slimmed-down Senate measure to pare back selected pieces of the 2010 healthcare law failed, undermining the GOP leaders' efforts to deliver on a longtime campaign promise. Sen. John McCain (R-Ariz.) cast one of three Republican "no" votes that effectively sank the Senate GOP's latest attempt to roll back a handful of elements of the law. Sens. Susan Collins of Maine and Lisa Murkowski of Alaska also joined with Democrats to block the measure by a 49-51 margin. This latest outcome leaves Republicans without any clear next step in their months-long campaign to roll back the ACA.


Congressional Democrats have proposed a strategy for reducing the cost of prescription drugs in the United States to halt large price hikes and give the federal government more leverage over what Medicare pays for medicines. "Right now, there is nothing to stop vulture capitalists from egregiously raising the price of lifesaving drugs without justification," says Senate Minority Leader Sen. Chuck Schumer (D-N.Y.). "We're going to fight for rules to stop prescription drug price gouging and demand that drug companies justify price increases to the public." The Democrats' plan calls for the inception of an independent, Senate-confirmed price gouging enforcer to identify medicines with "unconscionable" price increases and hit manufacturers with penalties that are proportional to the size of the price hike. Money paid will be allocated to the National Institutes of Health to further its work on new drug development. Drugmakers would need to justify what are deemed excessive price increases to the Department of Health and Human Services at least 30 days before the hikes go into action. This justification would be made public and include information, such as how much federal funding was involved in the drug's development and its total marketing cost. In addition, the government would be permitted to negotiate the cost of prescription drugs covered by Medicare Part D.


A new blog post from the U.S. Government Accountability Office (GAO) focuses on the reasons underlying little use of electronic health records by patients. In a GAO report, interviewed patients were aggravated by the amount of time and effort it took to set up patient portals, understand each portal's user interface and manage all the different passwords. In addition, most healthcare providers routinely provide access to lab test results, information about allergies and current medications, but patients said that the information available to them was not complete or consistent across providers. There was also little clarity about whether this information could be electronically downloaded, transmitted or aggregated in one place. Moreover, patients noted they were able to use the portals to better talk to providers, track health information and share this information with other providers. GAO determined patients typically accessed their records before or after a visit with their provider. Patients also said they used these portals to access "convenience features," such as appointment scheduling and reminders and medication refill requests.

Medicine, Drugs and Devices

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A total of 287 entities applied for the new ".health" domain extension earlier this year. The ".health" ending is intended for healthcare brands, with the company that manages the domain, dotHealth, set to open registration to the healthcare industry this month. DotHealth's intention is for the top-level domain extension to be used by the healthcare industry to signal that its websites contain reliable health information. The domain was a popular one, with four companies jockeying for the rights to it in 2012 when the Internet Corporation for Assigned Names and Numbers decided to add more to the 21 that existed then. To ensure the domain is effectively used, the dotHealth team wrote policies aimed at preventing owners of ".health" domain names from improperly using the sites.


A recent study published in Clinical Toxicology found a rising rate of serious medication errors made by the people taking those medications. The researchers analyzed calls to poison control centers across the United States, determining that approximately 14 daily calls relate to serious medication errors, most requiring medical treatment and some leading to hospitalization or even death. Study author Nichole Hodges says there was a doubling of serious medication errors between 2000 and 2012, with the most common mistakes concerning cardiovascular drugs, which comprised 20.6 percent of serious errors. Pain medications, such as opioids and acetaminophen, were associated with 12 percent of errors, and hormone therapies, primarily insulin, were involved with 11 percent.


Samsung is now offering an arthritis drug in the United States. The medicine is a copy of Johnson & Johnson's rheumatoid-arthritis drug Remicade. The drug will be marketed by Merck & Co. and will be sold for 35 percent less than Remicade's list price. The drug marks Samsung's entry into the pharmaceutical industry through its Samsung Bioepis Co. business. That company will focus on developing replicas of branded biologic drugs. Experts believe the market for biosimilar drugs will expand as patent protections begin to expire.