News From ACFAS

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If you attended ACFAS 2019 in New Orleans last month, log into acfas.org to access your Certificate of Attendance.

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Once you log in, you will be linked directly to the ACFAS Education Documentation and CME Tracking Center where you can print your certificate and a listing of sessions you attended.

Your user name is your primary email address. Your password is your ACFAS ID number plus your first and last initial (lower case), or log in using the unique password you created.

Contact Marilyn Wallace, ACFAS Assistant Director of Education Curriculum and Alliances, at wallace@acfas.org if you have any questions. Looking to build strong relationships with other physicians in your area or to increase referrals to your practice? Then log into the ACFAS Marketing Toolbox to access our complete suite of Take a New Look at Foot & Ankle Surgeons referral resources.

From fact sheets and referral guides to PowerPoint presentations and videos, these free tools show other local physicians why they should send their foot and ankle patients to you for evaluation and treatment. A fact sheet and referral guide focused specifically on diabetes care are also included for maximum outreach.

Log in at acfas.org/marketing then click on “Increasing Referrals to Your Practice” under Healthcare Provider Marketing Tools to begin using these resources in your practice now. A little extra interest earned on your savings can be lifesaver for your practice when unexpected expenses arise. New equipment purchases, EHR system upgrades and any office remodeling projects run much more smoothly when your financial reserves are strong and solvent.

HACU, an ACFAS Benefit Partner, offers accounts to help you earn 4.0 percent annual percentage yield for 40 months. Visit hacu.org to learn more.

Foot and Ankle Surgery

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A study analyzed the interobserver and intraobserver agreement of a descriptive system for ankle fractures and the Lauge-Hansen classification. Three groups of observers—experts, semiexperts and novices—scored a total of 20 ankle radiographs, which were classified according to the Lauge-Hansen and Danis-Weber classifications. The ankle fractures were subsequently reviewed in a descriptive manner for number of affected malleoli, type of fracture of the lateral and medial malleolus and congruence of the ankle joint. After 14 days, the same set of radiographs was reviewed.

The interobserver agreement for the Lauge-Hansen classification was moderate for the experts, fair for semiexperts and slight for novices. All variables of the descriptive system had better interobserver agreement than the Lauge-Hansen classification, save for the agreement on the type of fracture of the lateral malleolus. The intraobserver agreement of the Lauge-Hansen classification was significant for the experts, moderate for the semiexperts and fair for the novices. The intraobserver agreement was improved for all factors of the descriptive system compared with the Lauge-Hansen classification.


A study was conducted to evaluate and compare the effect of combined mechanism ankle support (CMAS) with soft ankle support (SAS) and custom-molded foot orthosis (CFO) on static and dynamic postural control in patients with Chronic ankle instability (CAI). Twenty-two patients with CAI and a matching healthy cohort were evaluated in four orthotic conditions, including without orthosis and with the CMAS, SAS and CFO. Static balance was assessed in single-limb stance on the force platform, and dynamic balance was rated using the Star Excursion Balance Test (SEBT).

Statistically significant differences were observed for the main effects of the groups in all center of pressure (COP) parameters and reach distances in medial (M), anteromedial (AM) and posteromedial (PM) directions of the SEBT. The chief impact of the orthotics for all evaluated parameters, apart from reach distance in the PM direction, was statistically different. All COP parameters were significantly reduced with the CMAS in comparison with other orthotic conditions in CAI patients. Morevoer, the higher reach distances with the CMAS were obtained in the AM and M directions of the SEBT.


A network meta-analysis was conducted to assess the effectiveness of surgical treatments of adult acquired flatfoot deformity (AAFD) using direct and indirect evidences. The researchers searched PubMed, EmBase and the Cochrane Library to identify eligible studies conducted through November 2018, with a traditional meta-analysis using a random-effects model also used to evaluate the pooled outcome of the network meta-analysis. A total of 21 studies were analyzed.

Network meta-analysis results based on lateral angle talocalcaneal-calcaneal pitch (LAT-CP) suggested medial displacement calcaneal osteotomy (MDCO) has the highest likelihood to be the best course of AAFD treatment, but analyses based on anteroposterior talo-first metatarsal (AP-TMT1) and lateral angle talocalcaneal talo-first metatarsal (LAT-TMT1) implied that lateral column lengthening (LCL) was the best treatment. Analyses based on lateral angle talocalcaneal-arch height, anteroposterior talocalcaneal (AP-TC), lateral angle talocalcaneal-talocalcaneal (LAT-TC), anteroposterior-talonavicular coverage (AP-TNC), talonavicular coverage (TNC) and the American Orthopedic Foot and Ankle Society (AOFAS) suggested triple arthrodesis (TAO) as optimal.

Furthermore, double arthrodesis (DAO) yielded the best treatment effect on the function score. In traditional meta-analysis, the summary of standardized mean differences (SMD) suggested the surgical interventions are associated with significant improvements in LAT-CP, LAT-arch height, AOFAS, AP-TMT1, LAT-TMT1, AP-TC, LAT-TC, AP-TNC, TNC and function score.

Practice Management

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Physicians are lawfully mandated to protect any and all information within their control that a third party could use to identify one of their patients. The payment exception stipulated by the Health Insurance Portability and Accountability Act (HIPAA) only allows physicians to disclose protected health information to third parties, such as insurance firms or other providers, for the purpose of collecting a payment for provided health services. The Payment Card Industry's Data Security Standards also require health providers to maintain reasonable and appropriate protections to shield credit card information, or risk incurring significant penalties.

Best practices for accepting payment cards in healthcare environments, irrespective of transaction method, include not storing unencrypted sensitive payment card data in electronic form. Also advised is to upgrade to payment terminals that support EMV chip card technology for point-of-sale or point-of-care transactions, which is especially relevant because the liability for card fraud has shifted from card companies to medical practices. A third recommendation is to understand that not all encryption techniques are the same, and the fourth best practice is to ask the payment card merchant services provider to sign a HIPAA Business Associate agreement.


There is a body of thought that physicians could train themselves to be more empathetic through acting lessons. A study from the American Psychological Association found that teaching role-playing helps medical students appear empathetic and also enables true empathy. Most medical students start out with extremely high levels of empathy, yet the rigors of third-year clinical rotations often cause those levels to plunge. Learning how to act empathetically appears to offset this reduction in empathy. Another study found people who are naturally introverted are actually happier when they act, or pretend, to be extroverted. It is suggested that physicians take an acting workshop, find a community theater group online or simply partner with a friend or two to practice empathy and get feedback. Even practicing in front of a mirror or recording yourself can be helpful.


A study was conducted to investigate online ratings and comments of orthopaedic foot and ankle surgeons, with the team identifying factors affecting ratings and comments for this subgroup. The team selected 210 orthopaedic foot and ankle surgeons from the American Orthopaedic Foot and Ankle Society website. Demographic information, ratings and comments were reviewed on the three most visited public domain physician ratings sites, including HealthGrades.com, Vitals.com and Ratemds.com. Content differences between positive and negative comments were assessed.

The average review rating was of 4.03 plus or minus 0.57 out of 5 stars, and 84 percent of the total number of ratings were either 1 star or 5 stars. Most positive comments referred to outcome, physician personality and communication, whereas most negative comments related to outcome, bedside manner and waiting time. Analyses showed statistically significant proportions of positive comments pertaining to surgeon-dependent factors and negative comments relating to surgeon-independent factors.

Health Policy and Reimbursement

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The chief executives of seven pharmaceutical companies defended their pricing and business policies at a hearing of the Senate Finance Committee. Although the CEOs agreed drugs should be more affordable for Americans, they were hesitant to commit to price reductions without additional reforms. Their argument was that other contributors, like pharmacy benefit managers who negotiate discounts and insurance coverage, play a bigger role in how much consumers pay. Merck CEO Kenneth Frazier described pricing as "complex and interdependent," and noted addressing cost, access and affordability would require bringing "all the parties around the table." Patents grant drug companies exclusive rights to sell a drug for several years before generic companies can make competing versions.

Sen. John Cornyn (R-Texas) stated, "I support drug companies recovering a profit," but "at some point, that patent has to end, that exclusivity has to end," so Americans have access to more affordable generics. Other lawmakers questioned whether Americans are subsidizing the cost of new drug development for the rest of the world, through higher list prices charged to U.S. consumers compared to other developed countries and taxpayer-funded research grants that cover early scientific discoveries that might lead to new medications.


The U.S. healthcare and insurance industries are prepping a massive lobbying effort to defeat Medicare-for-all proposals floated by Democrats. The lobbyists are pushing the concept that the Affordable Care Act (ACA) is performing reasonably well and should be enhanced, not repealed by the GOP or replaced by Democrats with a new public program. The lobbying coalition alleges that Medicare for all will require tax hikes and will give politicians and bureaucrats control of medical decisions currently made by doctors and the people they treat.

Among the coalition's new members are the American Medical Association, the American Hospital Association and the Blue Cross and Blue Shield plans. Sen. Debbie Stabenow (D-Mich.) calls such a criticism "a knee-jerk reaction to anything that expands Medicare," stressing that a buy-in option is especially important for Americans in the 50 to 60 age bracket. Although the coalition is vehemently opposed to any proposals that sound like socialized medicine, it wants to expand Medicaid under ACA in Texas, Florida and other holdout states.


House Democrats have unveiled details of a Medicare for All bill that would create a new federally financed health system. The legislation to be introduced Wednesday with Reps. Pramila Jayapal (D-WA), Debbie Dingell (D-MI) and others is largely symbolic because Republicans hold the Senate and the White House, and it even faces an uncertain future in the Democratic-led House. Under the Medicare for All Act of 2019, the federal government would pay for health coverage for every American, including premiums, copays or deductibles. It would expand the Medicare program for older adults to younger Americans, replacing Medicaid for those with low income or disabilities and for most employer-sponsored coverage.

Employers and private insurers would be barred from providing benefits or selling coverage that duplicates benefits, but they could provide supplemental coverage. Benefits would include primary care, prescription drugs, dental care, substance abuse and mental health treatment, full reproductive services, as well as long-term care. The transition to the new system would take place over about two years. "We are very excited to get to work on providing true universal coverage. ... Americans are literally dying because they can't afford insulin or the cancer treatment they need," Jayapal said. The bill will likely spur stiff opposition over its potential cost.

Medicine, Drugs and Devices

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A study of ankle injuries detected via magnetic resonance imaging (MRI) at the 2016 Olympics found 21 percent of such injuries were preexisting. Of the 11,274 athletes who participated in the Olympics, 89 were referred for an ankle MRI, with nearly half of the MRIs performed on track and field athletes. Scan analysis determined 99 percent of the athletes had at least one abnormal finding, for an average of 6.2 abnormal findings per exam. Seventy-nine percent of the preexisting injuries were caused by an acute or subacute injury.

Tendon injuries were the most common acute injuries, with a majority low-grade and occurring in ball sport athletes. The most preexisting injuries per athlete were in non-ball sport athletes and occurred in the anterior talofibular ligament. The researchers suggest the results could potentially improve the image-guided care of athletes moving forward. The study was published in Academic Radiology.


The U.S. Food and Drug Administration (FDA) has approved colchicine oral solution for the treatment of gout flares. It is the first liquid formulation of the therapy approved by FDA. Physicians using colchicine to treat gout must frequently adjust dosing or interrupt patient treatment to address the drug's interaction with other treatments. The new liquid, oral formulation allows physicians to make simpler dosage adjustments for their patients than capsule and tablet formulations. The new therapy will also help the estimated 15 percent of older adults who have difficulty swallowing capsules or tablets.


U.S. Food and Drug Administration (FDA) Commissioner Scott Gottlieb has outlined the steps his agency is taking this year to fight the opioid epidemic. Noting that addressing the crisis is one of the agency's top public health priorities, Gottlieb reviewed actions the agency took against opioids in 2018 and said that this year, FDA will take further steps to build on those efforts. "We plan to implement the initial steps to require unit of dose packaging in the first half of 2019," Gottlieb noted. "Specifically, FDA is considering use of this new authority to mandate that certain solid, oral dosage forms of immediate-release formulations of opioid analgesics indicated for treatment of acute pain be made available in short-duration packaging for outpatient dispensing."