News From ACFAS

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We’re expecting our highest attendance ever here at ACFAS 2019 in New Orleans, and if today is any indication, we’re well on our way to reaching this milestone!

Attendees are already filling the convention center, excited to take part in preconference workshops and jazzed for tomorrow’s opening session with former Blue Angel John Foley. With a full slate of back-to-back workshops, sessions and sensational special events planned for the next few days, it’s no wonder this conference is set to make history!

If you can’t be with us here in New Orleans this week, mark your calendar for next year’s Annual Scientific Conference, February 19–22, 2020 in San Antonio, and we’ll see you then! Join the conversation here in New Orleans by using #ACFAS2019 in your social media posts. And no matter if you’re with us at the conference or back at the office, be sure to follow #ACFAS2019 on Twitter, Facebook, LinkedIn and Instagram so you don’t miss a minute of the excitement happening each day. Also view your colleagues’ posts, photos and videos through the #ACFAS2019 app’s social media feature. Congratulations to new ACFAS President Christopher L. Reeves, DPM, MS, FACFAS; Scott C. Nelson, DPM, FACFAS, President-Elect; Thanh Dinh, DPM, FACFAS, Secretary-Treasurer; and John S. Steinberg, DPM, FACFAS, Immediate Past President.

The new officers will be installed this Friday during the Honors and Awards Ceremony at ACFAS 2019 in New Orleans along with the new and returning Board members:

Eric A. Barp, DPM, FACFAS
Brian B. Carpenter, DPM, FACFAS
Michael J. Cornelison, DPM, FACFAS
Meagan M. Jennings, DPM, FACFAS
George T. Liu, DPM, FACFAS
Harry P. Schneider, DPM, FACFAS
Randal L. Wraalstad, DPM, FACFAS

A special thank you to retiring Board member Laurence G. Rubin, DPM, FACFAS, for his dedicated service. Help us maintain the quality and accuracy of the abstracts featured in each issue of This Week @ ACFAS by serving as a This Week content reviewer. We currently have an opening for one content reviewer.

As a content reviewer, you will receive a This Week preview every Friday. You would check the abstracts listed under each section (Foot and Ankle Surgery, Practice Management, Health Policy and Reimbursement, and Medicine, Drugs and Devices) for relevance and technical/medical accuracy and then email your changes and input to ACFAS staff for implementation.

If you are interested in this position, please contact Melissa Matusek, CAE, ACFAS director of Marketing and Communications, at melissa.matusek@acfas.org.

Foot and Ankle Surgery

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Displaced intra-articular calcaneal fractures can be difficult to treat. Open surgical techniques are associated with wound complications, whereas nonoperative management leads to arthrosis. In this study, 23 displaced intra-articular calcaneal fractures in 19 patients were treated with closed reduction and percutaneous Kirschner wire fixation. Sanders and Essex-Lopresti classification systems were used. Researchers studied anatomical (Gissane and Bohler angles and width of calcaneus) and functional outcomes after six, 18 and 26 months. Mechanism of injury, fluoroscopy use, time since injury, time delay to surgery, method of reduction and number of Kirschner wires used were recorded. The mean participant age was 29.5 years, mean delay to surgery was seven days, mean length of surgery was 61 minutes and mean fluoroscopy time was 115 seconds. All patients were followed for a minimum of 26 months, and the mean duration of follow-up was 32.4 months.

A total of 18 joint depression and five tongue-type fractures existed, whereas two Sanders type II, 13 Sanders type III and eight Sanders type IV fractures existed. The mean Maryland Foot Score and American Orthopaedic Foot and Ankle Society Ankle-Hindfoot Score at six months were 86.7 and 84.2, whereas at 26 months the scores were 87.7 and 85.1, respectively. No pin site infections, cases of sural nerve dysfunction or revision/additional surgery were experienced, and 17 patients were able to return to their original occupation at the end of 26 months.


A study was conducted to compare functional outcomes following open reduction internal fixation in ankle fractures with and without dislocation. A retrospective chart review of surgically treated ankle fractures over three years was performed with demographic data, type of fracture, operative time and complications recorded. Thirty-three of 118 patients eligible for analysis sustained a fracture-dislocation; patients were 46.6 years old, on average. Sixty-two patients, who had follow-up of at least a year, were analyzed for functional outcome via the Foot and Ankle Outcome Score (FAOS). The median follow-up time was 37 months. Demographic factors and FAOS were compared between ankle fractures with and without dislocation. The median age of patients sustaining fracture-dislocation was greater, while more patients were female and had diabetes. Wound complications were similar between both cohorts, and FAOS was generally poorer in the fracture-dislocation group, although only the pain subscale showed statistical significance.


Total ankle replacement (TAR) is gaining popularity as a treatment option for ankle osteoarthritis. Long-term implant survival is a critical outcome to determine the success of the TAR implant. The aim of this study was to analyze the survivorship of the Buechel-Pappas (BP) implant, a second-generation mobile bearing implant, at 10-year follow-up, make a subanalysis between patient groups and evaluate long-term functional outcomes. Data of 86 patients who received 101 BP implants between 1993 and 2010 were obtained from a prospectively documented database. Subanalyses were done for patients diagnosed with inflammatory joint disease and noninflammatory joint disease, and patients with preoperative tibiotalar neutral and nonneutral alignment. A Kaplan-Meier curve was used for survival analysis. Long-term functional outcomes were assessed with the following patient-reported outcome measures: Foot and Ankle Outcome Score (FAOS), Foot and Ankle Ability Measure (FAAM), Short Form-36 (SF-36) Stand Version 2.0 Health Survey and three anchor questions.

The survival rate of the BP implant at 10 years was 86 percent. A total of 31 patients required 55 reoperations, and in 13 patients, a revision procedure was performed. No significant difference in 10-year survival rate was found between either the inflammatory joint disease and noninflammatory joint disease group, nor the tibiotalar neutral and nonneutral alignment group. At a mean follow-up of 16.8 years for 21 patients, the mean FAOS activities of daily living (ADL) and FAAM ADL subscale scores were 75/100 and 56/100 points. The mean physical component summary and mental component summary of the SF-36 were 34/100 and 51/100 points, respectively.

Practice Management

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Doctors should take several steps to ensure a smooth retirement in the face of market volatility, according to W. Ben Utley, Certified Financial Planner and President of Physician Family Financial Advisors. These include establishing a "bond tent" in your investment portfolio, revisiting your life and disability insurance needs and eliminating debt. When asked what should be a top priority for doctors in the last few years of their careers, Utley warned against investing entirely in stocks. A bond tent will build in an added layer of security for doctors nearing retirement, Utley says. The bond tent model gradually moves your investments from historically less stable equities toward historically more stable bonds as you approach your retirement. Once you enter retirement, the model begins to gradually reverse itself, shifting toward stocks to generate late-retirement income. Utley also recommends that doctors revisit their life and disability insurance at the end of their career. "If you're dead certain that you're going to retire and you have enough money, you might want to consider canceling disability insurance. Know that this is a risky proposition, though," Utley says. Doctors nearing retirement should also aggressively pay down debt, including mortgages, student loans and credit cards, Utley says. Finally, he recommends doctors consider relocating to tax-friendly states.


Before a private practice jumps into an acquisition for purely financial reasons, managers and physicians should consider several factors, including the operational and cultural changes that will come along with any deal. An essential question is why the practice is making this move. If physicians are seeking acquisition because they do not like the business side of the practice, they are in for a surprise. The new administrators—whether a hospital or private equity group—are unlikely to let them off the hook. Once acquired, staff will be expected to act and comply with rules, protocols and regulations, even if they do not entirely make sense or are potentially detrimental from the practice's perspective.

Furthermore, physicians may need to give up the business aspects they enjoy, such as employee selection. Under a new regime, hiring tasks are the responsibility of human resources. Practice staff should consider whether they will be able to tolerate organizational layers and little ability to influence decision-making. Finally, managers and physicians should assess whether this is a culture in which they want to work. Consider the business and clinical philosophy, strategic vision, leadership and governance issues of an acquirer. The leading reason practices break apart and physicians pull out of hospital employment to return to private practice is lack of cultural fit.


The Institute for Critical Infrastructure Technology considers spearphishing to be an emerging cyberthreat that the medical community should prepared for. A recent American Medical Association survey found four out of five respondents had been the target of a cyberattack, with more than saying the attack was the result of a phishing lure. Few medical schools discuss cybersecurity in detail, despite healthcare's increasing dependence on technology—and hacks can affect both patient safety and patient satisfaction. Among the potential effects of spearphishing that McKinsey & Co.'s James Kaplan says providers should be concerned about are theft of protected health and practice financial data. Even worse is the possibility of being locked out of electronic health records (EHRs) or medical devices. According to Kaplan, a disguised spearphishing attack could be flagged if the emails tell recipients they need to click immediately or if they feature return email addresses or Web links with O's replaced with zeros or L's with ones. Providers should also educate and train staff about proper cyber hygiene practices, and those who use personal devices to interact with EHRs or supply medical information should share those practices with patients as well.

Health Policy and Reimbursement

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In his State of the Union address, President Trump laid out a series of health-related goals, including some that Democrats indicated could be areas of bipartisan negotiation or compromise. Trump vowed to take on prescription drug prices, pursue an end to the HIV epidemic in the U.S. by 2030 and increase funding for childhood cancers. The most likely ground for bipartisanship will be the issue of drug prices, with Democrats cautiously optimistic about achieving bipartisan legislation this year targeting prescription drugs. During the speech, Trump asked Congress to pass legislation to deliver "fairness and price transparency for American patients."

In addition, Trump vowed that his budget "will ask Democrats and Republicans to make the needed commitment to eliminate the HIV epidemic in the United States within 10 years." He also promised that his budget will seek new funding to expand research into cures and treatments for childhood cancer. Trump said he will seek "$500 million over the next 10 years to fund this critical lifesaving research." He also praised his administration for eliminating Obamacare's individual mandate penalty, the congressional passage of a "right-to-try" bill intended to make it easier for terminally ill patients to gain access to experimental medications and a decline in drug prices, although prices for many individual drugs are still rising.


Rep. Lloyd Doggett (D-Texas), the leader of the Ways and Means Health Subcommittee, has offered a proposal to require the U.S. Department of Health and Human Services (HHS) to negotiate prices for drugs covered by the Medicare prescription drug benefit. A companion bill was introduced in the Senate. House Democrats are expected to debate the legislation, although Senate Republicans are unlikely to take up such a plan. The measure includes tactics to urge drugmakers to reach an agreement with Medicare on a price.

Under Doggett's proposal, HHS would negotiate prices for prescription drugs covered by the private plans in Medicare Advantage and the Part D program using a set of factors. To encourage drugmakers to negotiate, HHS would issue a competitive license allowing generic manufacturers to produce the drug at a lower cost and to provide compensation to the original manufacturer if the department and the brand-name pharmaceutical company did not reach an agreement. A generic manufacturer that produced a drug under a competitive license would receive expedited review of the product from the U.S. Food and Drug Administration. While a generic company developed a drug and waited to secure approval, the price of the drug from the original manufacturer would be based on the average price of the drug of countries in the Organization for Economic Cooperation and Development with half the gross domestic product of the United States.


Democrats on the House Energy and Commerce Committee have announced they will hold a hearing to consider legislation to overturn conservative actions President Trump has taken on the Affordable Care Act (ACA). The panel will consider bills to overturn Trump’s expansion of cheaper insurance plans and to restore funding for outreach efforts to enroll people in Obama Care plans. A third bill would overturn guidance from the White House that makes it easier for states to make conservative changes to Obama Care. The bills have little chance of passing through the GOP-controlled Senate, but they provide Democrats a chance to show their priorities and to highlight Trump's actions. Republicans, meanwhile, argued that they support protections for people with preexisting conditions and would act to restore them if Obama Care were overturned. Democrats have said GOP attempts to repeal the ACA, which includes those protections, undermines that claim.

Medicine, Drugs and Devices

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A study determined that U.S. counties where opioid manufacturers offered a large number of gifts and payments to physicians witnessed more overdose fatalities involving the drugs than counties where direct-to-physician marketing was less pervasive. The drug sector spent about $40 million promoting opioid medications to nearly 68,000 doctors from 2013 through 2015, including payments for meals, trips and consulting fees. For every three additional payments that those companies made to doctors per 100,000 people in a county, overdose deaths involving prescription opioids there rose by 18 percent 12 months later. In that same period, about one in 12 doctors received opioid-related marketing, including one in five family practitioners. Counties where physicians received more industry marketing consequently experienced growth in both the number of opioids prescribed and opioid-related overdose deaths. Opioid-related spending on doctors was most highly concentrated in Northeast counties, while Midwest counties had the lowest concentration. Especially striking was the observation that the number of marketing interactions with doctors had a stronger association with overdose deaths than the amount spent.


Johnson & Johnson will start adding the price of its medicines to television commercials by next month, becoming the first drugmaker to take that step. It will include both the list price of a product as well as potential out-of-pocket costs that patients will pay. U.S. Department of Health and Human Services Secretary Alex Azar praised the move. Last May, Azar's office released a blueprint for reducing the cost of drug prices, which included a proposal to require disclosure of list prices in television advertisements for drugs. "We commend Johnson & Johnson for recognizing the value of informing consumers about list prices and for doing so voluntarily. We call on other manufacturers to follow their lead," Azar said.


The Trump administration has been trumpeting a parade of generic drug approvals by the U.S. Food and Drug Administration (FDA) over the past two years, but nearly half of those newly approved drugs are not being sold in the United States, Kaiser Health News has found. While FDA has approved more than 1,600 generic drug applications since January 2017, more than 700, or about 43 percent, of those generics still were not on the market as of early January. Thirty-six percent of generics that would be the first to compete against a branded drug are not yet for sale. Experts cite a variety of factors, including vast industry consolidation that has reduced the ranks of companies willing to purchase and distribute generics. In some cases, makers of generics obtain approvals and ultimately make a business decision not to sell them. "It's a real problem because we're not getting all the expected competition," said FDA Commissioner Scott Gottlieb. An FDA analysis concluded that it takes five generics on the market to drive prices down to 33 percent of the original brand-name price.