News From ACFAS

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Need three reasons to come to ACFAS 2019 in New Orleans early? Then register now for our new pre-conference workshops scheduled for Wednesday, February 13 and supercharge your coding and surgical skills in just one day! Choose from:

Coding and Billing for the Foot and Ankle Surgeon
(7:30am–5:30pm, 8 CE contact hours)
Challenge your coding and billing skills in actual scenarios and learn how to best use modifiers and codes for higher-level E/M services.
Register Now

Lateral Ankle Instability: It’s All About the Soft Tissues and the Bone
(7am–Noon, 4 CE contact hours, includes wet lab)
Discover new surgical solutions for pes cavus and lateral ankle instability in this hands-on cadaveric workshop. Practice repair options for mechanical deformities and soft tissue to achieve ankle stabilization.
Register Now

Grand Rounds: Optimizing Outcomes for Your Most Challenging Cases
(Noon–5pm, 4 CE contact hours, includes wet lab)
Short evidence-based presentations on First MPJ Fusion, Flatfoot (Non-Fusion Realignment), Ankle Fusion (Non-Charcot) and Bone Graft Harvest Options feature labs plus the chance to “choose your own adventure.” Then discuss recommendations and outcomes for audience members’ presented cases.
Register Now

For complete details on each workshop, visit acfas.org/neworleans. Everyone appreciates a little more time—take advantage of it! The College is extending the deadline to pay your ACFAS membership dues and avoid a late fee. A “last chance” reminder was sent out via email yesterday to all Fellow and Associate Members with 2019 dues outstanding.

Renew your membership now at acfas.org/paymydues or via mail or fax to continue your member benefits.

If you have questions or need another statement, please contact the Membership Department at (773) 693-9300 or membership@acfas.org. Residents, join us for Residents’ Day on Wednesday, February 13 in New Orleans!

Hear real-world guidance from experienced foot and ankle surgeons and learn how to:

• Prepare for interviews and present yourself as a top candidate
• Negotiate contracts
• Gain referrals and interact with other members of the medical community
• Manage difficult patients and surgical complications
• Get your name out there

Your registration fee includes lunch, a refreshment break and a networking post-meeting reception. Visit acfas.org/neworleans to register now! Poster presenters, no need to carry your poster to ACFAS 2019 in New Orleans! Use Call4Posters^™ to have your poster printed and shipped for convenient pickup onsite at the conference. Visit Call4Posters^™ for pricing and additional information.

Foot and Ankle Surgery

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An analysis was conducted to quantitatively assess radiographic measurement of the relationship between the transverse, sagittal and frontal planes in the hallux abductovalgus (HAV) deformity. Anteroposterior, lateral and sesamoid axial radiographs from 42 consecutive feet were evaluated with quantification of the first intermetatarsal angle, hallux abductus angle, metatarsal sesamoid position, first metatarsal inclination angle, sesamoid rotation angle and tibial sesamoid grade. Factors were mapped out against each other on frequency scatter plots with estimation of a regression line and Pearson's correlation coefficient. As transverse plane deformity increased, the frontal plane deformity also increased while the first metatarsal inclination angle decreased. An increase in frontal plane deformity also tended to accompany a decrease in the first metatarsal inclination angle. This study represents the first quantitative and objective data in support of a triplanar component to the HAV deformity, and the researchers argue this reinforces the assessment of the deformity with emphasis on all three planes.


The purpose of this study was to assess the impact of syndesmotic screw fixation on overall clinical outcomes following Weber B-type ankle fractures. A total of 21 patients with syndesmotic rupture requiring screw fixation were compared to 40 patients with an intact syndesmosis. Olerud-Molander-Ankle-Score, American Orthopaedic Foot and Ankle Society ankle hindfoot score and the Short Form Health Survey-36 were recorded. Weightbearing plain radiographs were performed to rate posttraumatic osteoarthrosis according to the Kellgren-Lawrence score. Pain levels were evaluated with a visual analog scale. A total of 61 patients with a mean follow-up of 6.6 years satisfied the inclusion criteria. Pain level, clinical outcome scores and radiographs did not reveal significant differences between the groups. Ankle joints with syndesmotic rupture showed a significant restriction in dorsiflexion compared to those with an intact syndesmosis. The researchers concluded that syndesmotic rupture does not affect clinical and radiological outcome parameters following Weber B-type ankle fractures, but it leads to a significant restriction in dorsiflexion of the ankle joint.


A study was conducted to investigate the positive and negative factors correlating with different clinical and radiographic outcomes of total ankle arthroplasty (TAA). The systematic review of 89 studies determined that older patients noticed less pain or stiffness and demonstrated less radiographic loosening that did not require additional surgical intervention. More traumatic arthritis exhibited adjacent joint degeneration after TAA. Meanwhile, less experienced surgeons had more intraoperative complications, and the study found that a dearth of experience for complications management without implant retrieval during the early period might lead to more revisions or fusion.

Furthermore, updated instrumentation was found to lessen malalignment, and if the polyethylene (PE) insert was significantly narrower than the metal components, more implant instability and subsequent severe particulate wear was observed. Designs with flat-on-flat articulation and a ridge at the center of the talar component were linked to more PE fractures, while minimal bone resection reduced postoperative fractures. A flat cut of the tibial component and a flat undersurface with press-fit by two screws or pegs of the talar component exhibited fewer postoperative fractures, and a syndesmosis fusion and a small triangular shape with one central fin of the talar component demonstrated more loosening that required no additional surgery. The anatomic conical shape of the talar component appeared to reduce adjacent joint degeneration, and fewer failures were seen in patients who underwent HINTEGRA and Salto Talaris.

Practice Management

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Credentialing a new provider is a tedious process in which every mistake or delay can affect your bottom line. However, the process can be expedited by following several tips. First, start early. Set a goal of getting all the necessary documentation and references from an incoming provider as soon as possible. Since slow credentialing affects the practice's finances, also consider linking a provider's start date to his or her credentialing paperwork submission. Furthermore, ask providers for five instead of three references. Since most payers and health systems still require three professional references and will not begin the credentialing process until everything is received, one lagging reference can halt the whole process.

Next, be proactive. Notify credentialing staff when you submit an application and check in weekly to make sure everything needed was provided, especially during the summer, when payers and health systems are overloaded with new provider applications. Also consider outsourcing credentialing, which can reduce the process by weeks or months. Furthermore, scrutinize for accuracy and completeness before submission. Most applications are delayed due to errors or omissions, which typically include incomplete work or malpractice history, missing professional references, unconfirmed hospital privileges/covering colleagues and outdated information on the Coalition for Affordable Quality Healthcare's credentialing database. Finally, know your state's regulations for timely credentialing. Check with your state medical society or state Medical Group Management Association chapter to ensure you are optimizing the use of any applicable regulations.


This new year, pick a resolution that will help you grow as a physician and improve your business. Here are a few to consider for 2019. First, learn something new. By continuing to adapt and learn, you will be better able to execute your vision. In addition, identify areas that you are weakest at and make sure to work on them in 2019. Second, delegate more. Review your workload from the past year and find a way to lighten it. You are surrounded by a talented staff of peers, so do not be afraid to ask for help.

Third, do not settle. Odds are some part of your practice did not work the way it was supposed to this past year. Instead of telling yourself you will get to it later, make a plan now that you can take action on before it becomes another resolution that fell through. Finally, improve communications. Do not leave your staff guessing about what they should do; tell them what they need to do and when you need them to do it by. Patients should also be kept in the loop, whether through an online portal or a monthly newsletter. Make sure that patients are kept up to date with their treatment information and on changes happening within your practice. With clear lines of communication, your practice will continue to run smoothly and will address issues efficiently.


Referrals are increasingly being driven by pressure to keep business within a hospital system, even if an outside referral might benefit the patient, according to documents and interviews with doctors, hospital executives and lawyers. Doctors working for Albany, Georgia-based Phoebe Putney Health System's affiliated physician group receive regular reports breaking down their referrals to specialists or services. If the share of in-house business was not considered adequate, administrators would pressure them to improve, doctors said. Phoebe officials countered that they use referral policies to improve quality and reduce costs and that physicians were not punished for their decisions.

Hospitals have gained more power over doctors with a wave of acquisitions of practices and hirings in recent years and are getting more aggressive in directing physicians' referrals. Yet hospitals' efforts to avoid "leakage," or losing patients to competitors, can mean higher costs for patients and the employers that insure them. Federal rules generally block hospitals from directly tying physicians' pay to referrals because of worries that factors other than patient needs could affect physicians' decisions. However, doctors and hospital officials said that hospitals make the goals clear in ways both subtle and overt. Some hospitals have employment contracts that mandate doctors refer within their system, with a few exceptions required by law. In electronic medical records, a system's own specialists and services are sometimes located in a convenient drop-down menu, while referring to an outsider requires additional steps. A 2016 survey of hospital executives by Nielsen Strategic Health Perspectives found that 55 percent were actively managing, or planning to manage, referrals to keep them inside their systems.

Health Policy and Reimbursement

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House Democrats on January 3 quickly used their new control of the chamber to defend the Affordable Care Act (ACA), taking the first step to intervene in a court case in which a Texas judge ruled the healthcare law unconstitutional. As part of its rules package for the 116^th Congress, the party is granting itself permission to intervene in the Texas court case and allowing the chamber's counsel to work on the litigation. The move will be followed by a January 9 vote designed to pressure Republican lawmakers into a political corner, either putting them on the record defending or appearing to oppose the law.

The House move came hours after a coalition of Democratic attorneys general appealed the ruling by U.S. District Judge Reed O'Connor that the ACA is invalid, launching a process that could bring the law before the Supreme Court for a third time. The appeal, to the U.S. Court of Appeals for the 5^th Circuit, begins the case's path through the judiciary after O'Connor agreed that the law would remain in effect in the meantime. The appeal by 16 states and the District of Columbia consists of a single paragraph that details the legal steps to this stage. California Attorney General Xavier Becerra, leading the opponents of the decision, and other coalition members blasted the ruling, declaring it is "reckless," "ludicrous" and based on a "flimsy" legal theory. Becerra said the ruling "threatens the entire healthcare system."


The U.S. Supreme Court will soon consider a case that examines a legal strategy pharmaceutical companies use to defend themselves against patient lawsuits. Merck Sharp & Dohme Corp. v. Doris Albrecht began as a class-action lawsuit brought by thousands of patients who used Fosamax, Merck's osteoporosis drug. Patients claim that Merck failed to properly warn them about certain side effects, such as that taking the drug may increase their risk of fracturing their femurs. In the lawsuit, patients argue that the drugmaker violated state "failure to warn" laws, which require companies to warn consumers about any dangers of their products.

Merck argues that it attempted to warn patients by updating the drug label but that the U.S. Food and Drug Administration (FDA) did not allow it. Merck claims it is not responsible for patients who suffered bone fractures because FDA blocked the proposed warnings from the label. The Supreme Court will determine how companies can use this defense, commonly employed by drugmakers to rapidly resolve cases and to avoid patient lawsuits. "Regardless of the outcome of the case, this will be a very big deal because [this defense is] a really important issue with respect to drug manufacturer liability," said Patti Zettler, an associate professor at the Georgia State University College of Law and a former member of FDA's office of chief counsel.


Reed O'Connor, the federal judge in Texas who ruled the Affordable Care Act (ACA) was invalid, has issued a stay in the case allowing the healthcare law to remain in effect while the ruling is appealed. On December 14, Judge O'Connor ruled that the ACA's individual mandate was unconstitutional and that the rest of the law was therefore invalid, but he did not issue an injunction stopping the law from being enforced. On December 30, he said the ruling should not go into immediate effect "because many everyday Americans would otherwise face great uncertainty" during an appeal. He added that California and the more than dozen other states supporting the ACA were "unlikely to succeed" in their appeal. The case is likely to be taken up by the United States Court of Appeals for the 5^th Circuit in New Orleans, and many experts believe it will ultimately go to the Supreme Court.

Medicine, Drugs and Devices

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More than three dozen pharmaceutical companies upped the prices on hundreds of drugs in the United States at the beginning of the year, according to an analysis from Rx Savings Solutions. The average increase was 6.3 percent, the analysis found, including increases on different doses for the same drug. Many companies' increases are relatively modest this year, amid growing public and political pressure on the industry over prices. Yet a few are particularly high, including on some generics, which account for 90 percent of the prescriptions filled in the United States. Overall, price increases, including recently restored price increases from Pfizer, continue to exceed inflation.

Allergan set the pace with increases of nearly 10 percent on 27 products and about 5 percent on another 24 products. Allergan CEO Brent Saunders had said in 2016 that the company would limit itself to one price rise a year and keep those increases below 10 percent as part of a "social contract" with patients. Following the new price hikes, Allergan said it is "committed to responsible pricing principles" outlined in that pledge. Other drugmakers noted that their increases are small and are necessary for them to continue operating a sustainable business.


The U.S. Department of Health and Human Services (HHS) has issued new guidance to protect organizations in the healthcare sector from cyberattacks, the result of a requirement in the 2015 Cybersecurity Act. The report focuses on some of the most common threats against healthcare organizations, from email phishing to targeted attacks against connected medical devices, and provides basic best practice advice on how to spot and mitigate each threat. HHS Deputy Secretary Eric Hargan said the guidelines are meant to give both IT and non-IT healthcare professionals "practical, understandable, implementable, industry-led and consensus-based voluntary cybersecurity guidelines."

The size of an organization is one of the most "critical" cybersecurity variables identified by the task force, and it released technical supplements tailored to small, medium and large healthcare organizations. Smaller practices typically have fewer dedicated IT and cybersecurity staff but operate in a significantly less complex IT environment. Medium and large organizations tend to have more resources but are more geographically dispersed targets, share information with more partners and operate in highly complex IT environments that widen the attack surface for hackers. Vulnerabilities discovered in internet-connected medical devices have alarmed some lawmakers and regulators, although legislation designed to bolster cybersecurity requirements for these devices failed to pass in the last session of Congress.


Some states with the highest rates of fatal overdoses in 2017 are seeing those numbers flatten out or decline. In New Hampshire, the state medical examiner's office recently predicted there would be 437 drug deaths in 2018, a 10 percent drop from 2017, when the fatality rate plateaued. Before that, New Hampshire's overdose death rate had risen steadily since 2013. In Ohio, a longtime opioid hotspot, the state's health department says deaths from prescription opioids fell to an eight-year low in 2017, with the decline expected to continue into 2018.

The most recent provisional U.S. Centers for Disease Control and Prevention data show that the national overdose fatality rate appears to have leveled off in 2018. Drug epidemics tend to experience four phases: introduction, expansion, leveling off and declining, according to James Hall, an epidemiologist at the Center for Applied Research on Substance Use and Health Disparities at Nova Southeastern University in Florida. New Hampshire was an early hotspot for the fentanyl crisis and appears to be following this pattern, Hall said. "I think different regions across the country are experiencing the early days of the plateau phase," Hall said. He warned that data remains inconclusive and it is too early to declare that the overall death toll is declining.