News From ACFAS

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Congratulations to the newly elected ACFAS board members from online balloting that ended on January 22:

• Eric A. Barp, DPM, FACFAS
• George T. Liu, DPM, FACFAS

Previously elected to serve as chair of the Region Presidents Council and ex-officio board member:

• Harry P. Schneider, DPM, FACFAS

Drs. Barp and Liu will serve three-year terms (2018–2021). Dr. Schneider will serve a two-year term (2018–2020).

Also serving on the 2018–2019 Board of Directors are John S. Steinberg, DPM, FACFAS, President; Christopher L. Reeves, DPM, FACFAS, President-Elect; Scott C. Nelson, DPM, FACFAS, Secretary-Treasurer; Laurence G. Rubin, DPM, FACFAS, Immediate Past President; Michael J. Cornelison, DPM, FACFAS; Thanh L. Dinh, DPM, FACFAS; Meagan M. Jennings, DPM, FACFAS; and Randal L. Wraalstad, DPM, FACFAS.

The new board will be installed on March 23 during the ACFAS 2018 Scientific Conference in Nashville. If you missed last week's free webinar, "Take a New Look at Practice Building," log in to acfas.org/practicebuilding to access the complete recording.

Hear your colleagues Christopher L. Reeves, DPM, FACFAS; Amber M. Shane, DPM, FACFAS; and John S. Steinberg, DPM, FACFAS share their tips for using the marketing materials from the College's Take a New Look at Foot and Ankle Surgeons campaign to increase referrals and recruit new patients to your practice.

Melissa Matusek, CAE, ACFAS director of Marketing and Communications, also outlines how to use the resources in the ACFAS Marketing Toolbox to promote your practice to patients and other healthcare providers.

Log in now and learn how to put these materials into action! Come to the Gaylord Opryland Hotel in Nashville on Wednesday, March 21 to warm up your coding and surgical skills the day before the curtain rises on ACFAS 2018.

Take your pick of three preconference workshops designed to challenge you and give you a preview of the learning opportunities that lie in store:

Coding and Billing for the Foot and Ankle Surgeon
(7:30am–5:30pm, 8 CE contact hours)
Gain no-nonsense solutions to maximize your surgical billing processes and increase your reimbursement.

Tendon Transfers: Common to Complex
(7am–Noon, 4 CE contact hours, includes wet lab)
Master several tendon transfer techniques to better manage common deformities.

Common Corrective/Realignment Osteotomies
(Noon–5pm, 4 CE contact hours, includes wet lab)
Perform common forefoot and rearfoot osteotomies step by step with expert faculty.

Visit acfas.org/nashville to register and get a head start on your ACFAS 2018 conference experience! ACFAS has partnered up once again with Call4Posters™ for your poster printing needs. It is a simple and convenient way to have your poster printed and shipped for pickup on site at the meeting. Visit the Call4Posters™ site for additional information and fees. Attention all residency directors, codirectors, faculty chief residents and school deans: you are invited to attend the fifth annual Residency Directors Forum, hosted by ACFAS and the Council of Teaching Hospitals (COTH).

The Forum will take place on Wednesday, March 21 from 1:30 to 5:30pm at the Gaylord Opryland Hotel in Nashville the day before the ACFAS Annual Scientific Conference officially begins.

This year’s Forum will provide attendees useful information to assist in the overall growth of their residency program. Through direct interaction with the invited panelists, they will be provided with the tools needed to make a positive impact on residency education and training at their institutions.

Sessions will include:

• Show Me the Money: GME Funding Lecture
• Breaking the Code: The Latest in Logging—New & Improved
• Speed Dating: The Tinderbox—Answer Your Burning Questions
• Social Media Gone Wild: How Risky Is Your Social Media Footprint?
• Life Is Like a Box of Chocolates: Incoming Resident Selection and Education
• Path to the Future: Mentoring Through the DPM Mentors Network
• Sharing Is Caring: Program Collaboration and ACFAS Regional Support
• The Joys of Parenthood: Breakout Session
• Gin and “Juice” with a Twist: Open Bar, Open Mic, Open Your Mind

This invitation-only event is complimentary for up to two representatives per residency program. Chief residents must attend alongside their program director. Deans are also complimentary.

Download the registration form and submit it to Michelle Kennedy by March 2. Register early since space is limited. Please note there is no onsite registration.

Foot and Ankle Surgery

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The objective of this study was to determine if the postoperative alignment of the hallux influences the final clinical outcome of hallux metatarsophalangeal joint (first MTPJ) arthrodesis. A total of 71 consecutive cases (hallux rigidus) were studied in stages three and four that were operated through arthrodesis between 2008 and 2014. The mean follow-up was 7.3 years. The American Orthopaedic Foot and Ankle Society (AOFAS) test was performed preintervention and per annum. In radiology, both the hallux valgus angle and the dorsiflexion angle of the first MTPJ were studied. Furthermore, clinical outcomes were evaluated according to the type of implant used. Preoperative AOFAS score was 27.5, rising to 91.3 after the intervention. The improvement test average was 63.6. There were 17 local complications (23 percent). Seven of these were considered to be major complications (nine percent), six of which needed reoperation (8.5 percent). The mean postoperative dorsiflexion angle was 21.7°. The mean postoperative hallux valgus angle was 10.9°. No associations were found between either angle and improved AOFAS score or complications. Patients who had a dorsiflexion angle higher than 20° had greater improvement in the AOFAS score compared with those who had angles lower than 20°, but this result was not statistically significant. The researchers found that first MTPJ arthrodesis is a good alternative for patients in advanced hallux rigidus stages when conservative treatment fails. They obtained better results with dorsiflexion angle greater than 20° than with angle less than 20°.


Fifth minimally invasive distal metatarsal metaphyseal osteotomy (DMMO) for bunionette deformity is a safe and effective technique, according to a retrospective study published in Foot & Ankle International. Researchers examined 19 patients (21 feet) who had symptomatic bunionette deformity and failed conservative treatment between 2014 and 2016. Clinical data was collected, along with pre- and postoperative Manchester-Oxford Foot Questionnaire (MOXFQ) scores and visual analog scale (VAS) pain score. The mean follow-up was 28 months. The mean MOXFQ summary index score declined from 71 (range, 59-81) preoperatively to 10 (range, 0-30) postoperatively. All three MOXFQ domains also improved. The average improvement in VAS score was seven. Forefoot swelling and some painful symptoms took about three months to settle. There were no wound or nerve complications. One patient required a dorsal cheilectomy for a symptomatic prominent dorsolateral callus formation. The researchers concluded that minimally invasive fifth DMMO for bunionette deformity had relatively few complications and led to good clinical results. In addition, the researchers said it is important to warn patients that the forefoot swelling will take months to settle versus an osteotomy with fixation, and that there is a 10 percent chance of a prominent callus over the osteotomy site.


Evidence supporting the use of lesion size and containment as prognostic indicators of success of bone marrow stimulation (BMS) for osteochondral lesions of the talus (OLTs) is of low quality, according to a new study in the World Journal of Orthopedics. The prognostic factors for BMS—a reparative procedure for OLTs—are lesion size and containment of the lesion. No other factors have been proven to be universal predictors. However, the level of evidence and methodological quality of evidence for clinical studies regarding both the lesion sizes and containment are low. To clarify the quality of these studies, researchers searched the PubMed/MEDLINE and EMBASE databases using the following key terms: osteochondral lesion of talus, arthroscopy, bone marrow stimulation and systematic review. Level of evidence (LOE) was gauged using previously published criteria by the Journal of Bone and Joint Surgery and methodological quality of evidence (MQOE) was assessed using the Modified Coleman Methodology Score. Of the 22 studies included in the review, 21 were level IV or level III evidence, one was level II evidence; no level I study was identified. MQOE analysis revealed 14 of the included studies had fair quality, seven had poor quality and one had excellent quality. Specifically, the scores of "primarily evaluates outcome criteria and recruitment rates" were low, the study found.

Practice Management

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For every hour a doctor spends with a patient, s/he typically spends two hours completing paperwork, reviewing test results and managing several other tasks. This addition to the workload also plays a role in career burnout. However, blockchain technology and artificial intelligence (AI) could ease some of the burden doctors face with the tasks they must manage on the job. For example, blockchain technology can simplify the usage of electronic health records and other patient data. Meanwhile, AI can be potentially used to help doctors make better decisions. Digital Reasoning is a start-up that uses algorithms to give doctors a better view of a patient's health, which can lead to more informed decisions by doctors concerning treatment. Still, obstacles exist for both innovations in the field.


Experts believe one of the more effective solutions for doctors experiencing burnout is to talk more with family. While family members may not understand the nuances of the job, they do have a clear understanding of a member of their household. Parents, siblings and adult children can be great sources of comfort and support in stressful times. They may also provide unique ways to solve nagging problems experienced on the job. Michael Myers, professor of clinical psychiatry at SUNY-Downstate Medical Center, says a doctor may not want to talk about work-related stress for several reasons. However, he warns that failure to talk to family could ultimately damage a career and a household. Myers adds, "Sharing strengthens the family."


The Trump administration plans to provide new exemptions for healthcare practitioners with moral or religious objections to performing certain medical procedures, including gender-reassignment surgery and abortions. The U.S. Department of Health and Human Services (HHS) sent a proposal on January 12 to the White House for review, a source says. HHS will also establish a division of "conscience and religious freedom protections" within its Office for Civil Rights, people familiar with the matter say. The new regulatory action is expected to state that physicians do not need to perform medical services if they assert a religious or moral objection to doing so. The administration earlier signaled it would revise a regulation, enacted by HHS under the Affordable Care Act, that prohibits discrimination in healthcare by healthcare providers who receive money from the federal government.

Health Policy and Reimbursement

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Organizations representing hospitals, physicians, medical groups, health insurers and pharmacists have announced an initiative to improve prior authorization processes that slow the delivery of treatment to patients. The groups say facilitating the prior authorization process might also help reduce administrative burdens for healthcare professionals, hospitals and health insurers. The groups have signed a consensus statement, pledging to cooperate on a variety of projects. In particular, the organizations are committing to accelerating industry adoption of national electronic standards for prior authorization and improving the transparency of formulary information and coverage restrictions at the point of care. Other objectives include improving communication between health insurers, healthcare professionals and patients to minimize delays in care.


U.S. House Speaker Rep. Paul Ryan (R-Wis.) said on January 12 that he doubts the House will pass Social Security or Medicare reform in 2018. His remarks follow President Trump's January 11 comments to the Wall Street Journal that he thinks the U.S. Congress will transition to a bipartisan infrastructure plan before moving on to welfare reform. U.S. Senate Majority Leader Sen. Mitch McConnell (R-Ky.) stated earlier that he does not think the U.S. Senate could pass a welfare reform bill on a partisan basis, as Republicans would have to gain nine Democratic votes to override a likely filibuster.


The U.S. Centers for Medicare and Medicaid Services (CMS) is refusing to process claims for occupational therapy, which will prevent seniors from being forced to pay out of pocket if they reach Medicare's annual ceiling of $2,010 for the services. Limits on therapy care are among the set of "Medicare extenders" that expired at the end of 2017 and have not been renewed by Congress. With some seniors expected to hit Medicare's cap beginning in January, the American Physical Therapy Association's Justin Elliott says his organization and others are asking CMS for clarification. CMS says it cannot process claims sooner than 14 days but usually pays them within 30 days. "If legislation regarding the therapy caps is not enacted in this short period of time, then CMS will release and process the therapy claims accordingly," the agency notes on its website. Medicare's limit on how much therapy it would pay for was effected in 1997 but has been overridden by Congress ever since. CMS says it is not holding claims for other Medicare extenders.

Medicine, Drugs and Devices

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A study published in The BMJ found duration of opioid prescription, not dosage, to be the strongest predictor of subsequent diagnosis of opioid misuse among surgical patients. The retrospective analysis of more than one million commercially insured U.S. patients determined each postsurgical opioid refill was associated with a 44 percent rise in misuse among opioid-naive patients. Furthermore, each additional week of prescriptions raised the risk of opioid misuse up nearly 20 percent, and misuse rates climbed when patients received more than nine weeks of drugs, although the risk was non-zero even with prescription durations shorter than two weeks. More than half of patients received prescriptions for opioids following surgery, 90 percent of which were filled within three days after discharge. In a follow-up spanning an average of 2.67 years, opioid misuse was identified in 0.6 percent of patients, with 1,857 occurring within 12 months after surgery. "Our study is highly suggestive of the conclusion that getting a refill increases your chances of opioid addiction," says Harvard Medical School's Gabriel Brat. "For surgical patients, it may be that we should focus less on the dose of opioids immediately after discharge and more on the length of time a patient is exposed to opioids." Although new-onset opioid misuse as described in the study was rare in the large sample, Dartmouth-Hitchcock Medical Center's Brian Sites cites the definition as a key constraint.


The U.S. Food and Drug Administration (FDA) will delay enforcement of certain unique device identification (UDI) system rules for class I and unclassified devices until September 24, 2020. The delay does not apply to implantable, life-supporting or life-sustaining devices. The FDA guidance says, "As FDA and industry have worked to implement these requirements, the agency has identified complex policy and technical issues that require resolution to help ensure that UDI data are high quality and are available in standardized ways."


Some of the largest U.S. hospital systems are planning to go into the drug business themselves in response to rising prices and occasional scarcities. "We will not lie down. We will go ahead and try and fix it," says Marc Harrison, MD, the chief executive of Intermountain Healthcare, the nonprofit Salt Lake City hospital group that is spearheading the effort. Several major hospital systems plan to form a new nonprofit company that will provide a number of generic drugs to the hospitals. The U.S. Department of Veterans Affairs is also expressing interest in participating. In all, about 300 hospitals are now included in the group. Other hospitals are expected to join.