News From ACFAS

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Join us On the Road April 26–27 in Orlando and May 3–4 in Houston for our “In the Trenches” workshop and seminar and come away feeling refreshed, renewed and ready to put your new perspectives to use in the OR.

This 12-hour CME program begins on Friday night with case presentations, “Controversies and Complications,” followed by a candid panel discussion and refreshments. Bring along your own work cases for feedback from panelists and your fellow attendees.

Continue on Saturday with a series of interactive lectures covering surgical approaches, foot fixation options and customized treatments for your patients. Challenge yourself in two hands-on sawbones labs then cap off your learning with proven “Tips, Tricks and Quips” from faculty.

Visit acfas.org/ontheroad to register now! If you missed Coding & Billing for the Foot & Ankle Surgeon at ACFAS 2019 in New Orleans, then be sure to join us July 26–27 in Dallas or September 20–21 in Teaneck, New Jersey for an encore performance of this popular seminar.

Faculty will show you how to accurately code and bill for a week’s worth of clinics, surgeries, calls, office procedures and complex cases. Gain valuable tips and tools you and your staff can use to streamline your existing processes and take that first step toward maximizing reimbursement for the care you provide.

This seminar closes with a breakout session dedicated to private practice and multispecialty practice and is worth 12 continuing education contact hours. Register now at acfas.org/practicemanagement. The recent manuscript and poster competitions at ACFAS 2019 proved that podiatric medical research is thriving. Continue this momentum by publishing your own original research study in The Journal of Foot & Ankle Surgery (JFAS) and reach a focused audience of foot and ankle surgeons, podiatrists, orthopaedic surgeons and other medical specialists.

Submit your article to JFAS for consideration using the newly upgraded Editorial Manager^® system, and visit jfas.org for info on the Open Access publishing option, Elsevier’s Researcher Academy and more.

Foot and Ankle Surgery

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A retrospective study was conducted to provide insights with respect to incidence of anterior inferior ligament avulsion fractures, the association with fracture type and correlation with treatment. A total of 252 adult patients with an ankle fracture operated on in a level-1 trauma center between January 1, 2009, and January 1, 2017, who had a pre- and postoperative computed tomography scan, were analyzed. Sixty-five patients were diagnosed with an anterior inferior ligament avulsion fracture, while none had a Wagstaffe type 1 fracture, 28 had a type 2, 32 had a type 3 and five had a type 4.

A correlation was observed between Wagstaffe type 2 and Weber B fractures and between Wagstaffe type 3 avulsions and Weber C fractures. Thirty-five of the avulsed fragments were smaller than 5 mm. In 13 patients with anterior inferior ligament avulsion fracture, the avulsed fragments were directly fixated during initial surgery. Size and direct fixation of the fragment were significantly correlated, while only four patients underwent a revision within the anterior inferior ligament avulsion fracture group.


A study was conducted to digitally explore intraobserver and interobserver reliability of various methods for measuring hallux valgus angle (HVA) and first intermetatarsal angle (IMA1-2), along with each axis composing them, such as axes of the first proximal phalanx (PP1), the first metatarsal (MT1) and the second metatarsal (MT2) in patients with a metatarsal shaft osteotomy-modified long oblique osteotomy. Three orthopaedic surgeons measured the HVA, IMA1-2 and the angles between axes of PP1, MT1 and MT2 and the digitally set reference line using six distinct methods for 39 patients with a minimum of 12 months' follow-up after operative treatment. The intraobserver and interobserver intraclass correlation coefficients (ICC) and agreements were calculated.

Significant differences were observed within the methods with regard to preoperative HVA, IMA1-2 a and ß and postoperative IMA1-2 and ß. Intraobserver and interobserver ICC were high or very high in most methods. For HVA and IMA1-2, the method linking the center of the head through the center of the base exhibited the highest agreement. For a, ß and y, this method had the highest agreement, more than 80 percent intraobserver and interobserver agreement and a discrepancy of less than 2 degrees. A digital method connecting the center of the head through the center of the base was deemed the least variable for the HV evaluation, and the assessment of the radiographic leads to a metatarsal shaft osteotomy-modified long oblique osteotomy.


A study was conducted to evaluate the number of steps and the amount of loading in a weightbearing orthosis in the initial six weeks following surgical Achilles tendon rupture (ATR) repair and to determine if the amount of loading correlated with fear of movement and/or experience of pain. Thirty-four patients with ATR repair were analyzed, with early functional mobilization allowed postoperatively in an orthosis with adjustable ankle range of motion. In the first 14 days, patient-reported loading and pain were assessed with a visual analog scale and step counts with a pedometer. At two and six weeks, a mobile force sensor was used for measuring plantar force loading, and the Tampa Scale for Kinesiophobia gauged fear of movement.

Between the first and second weeks, a significant increase in the mean number of daily steps taken was seen, along with an increase in self-reported loading. Patient self-reported loading significantly correlated with the plantar force measurement. At six weeks, loading was 88.2 percent on the injured limb versus the uninjured limb. Fear of movement did not correlate with pedometer data, subjective loading, pain or force data. However, patients with less pain during activity noted significantly higher subjective load and took more steps.

Practice Management

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A study published in The Lancet Psychiatry found physician-directed interventions eased symptoms of depression, anxiety and suicidality in physicians. Included in the meta-analyses was randomized, controlled studies or controlled before-and-after studies of interventions—both organizational-level and physician-directed—that sought to lower depression, anxiety or suicidality symptoms in physicians following intervention. The outcomes of studies examining symptoms of depression, anxiety or a combined measure suggested a moderate effect in favor of the physician-directed interventions.

An evaluation of suicidal ideation revealed that intern physicians who participated in a web-based cognitive behavioral therapy intervention were 60 percent less likely to report suicidal ideation during an internship year than the attention-control group. No evidence of significant heterogeneity was observed. The researchers concluded that, in view of the prevalence of mental health morbidity among physicians, the study's findings should both guide the type of physician-focused interventions that are adopted among this group and spur more comprehensive research on individual and organizational interventions aimed at improving the mental health of physicians.


A study has found many late-career physicians are putting off retirement, with 91 percent of poll respondents feeling they still can offer a useful service to patients. Fifty-one percent said that working occasionally or part-time is part of their ideal retirement plans, with one physician recommending they organize a financial plan early to ensure they have the freedom to pursue their interests upon reaching retirement age without having to worry about money issues.

Physicians tend to be busy and involved in their work, and few have cultivated many outside hobbies or other interests throughout the course of their career. However, 76 percent of surveyed physicians indicated that they would like to travel more in full retirement, and while making the decision to retire is difficult, it is something that many could look forward to eventually.


Consumer-grade information technology equipment is not recommended for medical practices, despite the oft-touted cost savings. Professional equipment is more expensive because it is made with better hardware, a fact especially apparent with devices that see heavy use, like servers and printers. Moreover, the software that runs on the hardware is essential and more likely to be the point of origin of a security incident or breach than the hardware itself.

Many home routers feature software that is nearly impossible to properly safeguard. Some open source projects have replacement software to make home routers more secure, but they do not offer enough security for medical practices. Professional-grade devices have a greater number of security feature options, and they can employ more secure wireless networking protocols, as well as reliable updates and patches from manufacturers.

Health Policy and Reimbursement

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Many residents of Summit County and across rural Western Colorado are struggling financially due to the high costs of medical services, but the creation of the nonprofit Peak Health Alliance aims to change that by negotiating lower hospital, clinic and physician prices on behalf of some of the area's biggest employers and then partnering with an insurance company to package those discounts into plans that dues-paying members can offer to employees or that residents can purchase on the Affordable Care Act exchange. Colorado Insurance Commissioner Michael Conway plans to try the strategy elsewhere, noting, "I will push for this to be something much bigger than the Summit County idea." He argues that the Peak Health Alliance could be the best way to use market forces to drive down healthcare costs in Summit County.


State regulators, insurers, hospitals and patient groups have submitted comments to the U.S. Centers for Medicare and Medicaid Services indicating that the agency should continue allowing states to engage in the practice of "silver-loading" or risk destabilizing the Affordable Care Act's insurance exchanges. Silver-loading occurs when an insurer raises premiums on a silver-level exchange plan to make up for the loss of cost-sharing reduction payments in 2017. "Removing the state option for actuarial loading would destabilize insurance markets that have otherwise recently achieved a beneficial equilibrium," according to comments from the National Association of Insurance Commissioners. "Such destabilization reduces insurer participation, reduces choice, increases costs and would raise costs for many Americans who obtain coverage through the individual market."


Rising income levels, better employment rate and more people enrolling for Medicare will cause U.S. health spending to grow at an average rate of 5.5 percent every year from 2018 over the next decade, according to the U.S. Centers for Medicare and Medicaid Services. Health spending will reach nearly $6 trillion by 2027 and will account for 19.4 percent of the U.S. economy. In 2017, healthcare spending accounted for 17.9 percent of the country's gross domestic product.

Spending projections for Medicaid and private health insurance plans are expected to average 5.5 percent and 4.8 percent, respectively, over the same period. Prescription drug spending is also expected to rise and average 5.6 percent annually between 2018 and 2027 as employers and insurers push patients with chronic conditions to adhere to medications better and as new and expensive drugs enter the market.

Medicine, Drugs and Devices

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U.S. Rep. Peter Welch (D-VT) has introduced a new bill that would allow patients to import cheaper insulin from other countries. Due to the lack of generic competition in the United States, insulin can cost people living with diabetes thousands of dollars each year. The bill would legalize importation of insulin from Canada by patients, pharmacists and wholesalers for two years and would then expand to other countries with safety standards similar to the United States. The bill would also require the U.S. Food and Drug Administration to certify and inspect all foreign exporters of insulin. A similar bill introduced in January by Rep. Elijah Cummings (D-MD) and Sen. Bernie Sanders (I-VT) and co-sponsored by Welch is more broad and would allow the importation of qualifying prescription drugs, excluding controlled substances.


The U.S. Food and Drug Administration (FDA) has unveiled new guidelines for the use of a novel pathway that offers incentives for the development of generic versions of drugs that have little or no competition. According to FDA Commissioner Scott Gottlieb, "This new pathway for Competitive Generic Therapies (CGTs) is a significant advancement in generic drug competition." He explained that a drug can be designated as a CGT when there is inadequate generic competition—that is, there is no more than one approved drug in the active section of the Orange Book. FDA has already granted more than 100 CGT designation requests, Gottlieb said, and between August and December 2018, the agency approved the first five abbreviated new drug applications for drugs designated as CGTs.


The U.S. Supreme Court has declined to review a federal appeals court's decision striking down Maryland’s bid to restore a law that state Attorney General Brian Frosh said was needed to protect residents from “monstrous price increases” by generic drug makers. The court’s decision was a setback to new efforts by states to keep down the cost of medicines. The law briefly went into effect, starting in 2017, before the 4^th U.S. Circuit Court of Appeals put it on hold with its decision in April 2018. The law was the first of its kind in the nation, although other states have considered similar measures. It applied to generic or off-patent drug makers that manufacture a medicine at least three other firms also make. If those conditions applied, companies could not impose a significant price increase without justifying it to the attorney general, who could ask a judge to order that the price increase not take effect. The appeals court held the measure violated the U.S. Constitution by trying to regulate trade beyond Maryland’s borders.