News From ACFAS

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Challenge yourself and further increase your confidence in the OR with our new course, Total Ankle Arthroplasty (TAA), set for September 6–8, 2019 at the Science Care Lab in Denver.

Perform implantation of all six ankle replacement systems approved by the U.S. Food and Drug Administration as you work alongside instructors in a hands-on cadaver lab. Sharpen your surgical decision-making and learn how TAA can help manage degenerative, posttraumatic and systemic ankle arthritis in your patients.

Also gain a better understanding of the indications for TAA versus ankle fusion, when to use supplementary procedures and how to resolve any complications.

This course is worth 17.5 continuing education contact hours and is limited to 16 participants. Visit acfas.org/skills to download the registration form and to determine if you meet the course prerequisites. Complete and fax the form with required documentation to (800) 381-8270 or email to hjelm@acfas.org. The road to proper reimbursement for the care you provide need not be long and winding. Find out how to simplify your current coding and billing processes in Coding & Billing for the Foot & Ankle Surgeon, July 26–27 in Dallas or September 20–21 in Teaneck, New Jersey.

You and your fellow attendees will work together to accurately code and bill for a week’s worth of clinics, surgeries, calls, office procedures and complex cases. Get tips on coding for:

• Forefoot, rearfoot and ankle reconstructive surgery
• Evaluation and management services
• Minor office procedures
• Amputation and diabetic foot surgery
• Complex arthroscopy

Instructors will also explain how to use modifiers to avoid denials and win appeals.

This seminar closes with a breakout session focused on private and multispecialty practices and is worth 12 continuing education contact hours. Spots are filling fast—register now at acfas.org/practicemanagement. If you could not make it to the sixth annual ACFAS Job Fair in New Orleans, you can still take advantage of the Job Fair virtually. Visit PodiatryCareers.org to post your resume online, view available jobs in your area or take advantage of ACFAS member discounts to post positions you are trying to fill.

The Job Fair will be back once again at ACFAS 2020 in San Antonio and will include open positions, resumes from job seekers and individual appointments with a professional resume reviewer. Watch for more details on how to participate as the event gets closer. Show your pride in your professional accomplishments and the College with merchandise from the ACFAS Logo Store, your one-stop shop for ACFAS-logoed gear. Shop 24/7 online through acfas.org for:

• Dress and casual shirts
• Fleece jackets and baseball caps
• Scrubs and surgical caps
• Coffee mugs and water bottles
• Professional pens
• Hoodies, t-shirts, socks and more!

Visit the ACFAS Logo Store anytime to check out all the available products, make your purchases and provide payment. Be proud of your professional achievements—and show off your pride in YOUR professional association!

Foot and Ankle Surgery

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A study was conducted to assess the clinical outcomes and safety of arthroscopic microfracture with the ankle suspended on a shoulder-holding traction frame for simultaneous anterior and posterior ankle arthroscopy in the prone position. Thirty-one patients with posterior osteochondral lesions of the talus were treated with arthroscopic microfracture in a suspended position with the patient prone between May 2010 and January 2016. Ankle distraction was achieved by suspending the affected ankle on a shoulder-holding traction frame.

The average 100-mm visual analog scale score and Foot Function Index improved from 62.8 plus or minus 11.3 and 48.5 plus or minus 12.1, respectively, preoperatively to 15.8 plus or minus 10.4 and 16.4 plus or minus 9.2, respectively, at final follow-up. Mean anterior, lateral, superficial posterior and deep posterior compartment pressures were 7.3 plus or minus 1.5, 8.1 plus or minus 1.1, 5.6 plus or minus 1.9 and 9.2 plus or minus 2.4 mmHg, respectively. There was no incidence of compartment syndrome.


A study was held to demonstrate the efficacy of fibular periosteum ligamentoplasty and extensor retinaculum flap in chronic lateral instability, involving 40 patients who underwent surgery for ankle instability. Thirty-three patients were reviewed, with an average follow-up of 8.2 years. Median Karlsson score was 95 while the mean decrease in varus laxity was 11 degrees (range 0 to 18) and in anterior drawer was 1 mm (range –8 to 4).

At the final follow-up visit, three patients exhibited evidence of osteoarthritis according to the preoperative criteria of the van Dijk classification, and six had radiologic changes, without narrowing of the joint space. In spite of the excellent control of ankle laxity, severe radiographic changes continue to evolve in the long term.


A study was conducted to detail the results of surgical treatment for trimalleolar fractures, identifying risk factors determining a worse outcome. Forty-eight patients with trimalleolar fracture treated with open reduction and internal fixation were retrospectively analyzed between January 2013 and December 2016. Average age was 44.69 years, and average body mass index (BMI) was 29.04. The Danis-Weber classification found 30 fractures were type B and 18 were type C.

The researchers observed no significant difference among the size of the posterior malleolus in patients with and without ankle dislocation, demonstrating no correlation between the size of the posterior fragment and ankle dislocation and the size of the posterior malleolus and syndesmosis stability. Being over 61 years old, a BMI higher than 40, an ASA higher than 1, a type C fracture and fracture dislocation were deemed negative prognostic fractures.

Practice Management

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A study in the New England Journal of Medicine shows the more malpractice claims a doctor accrues, the greater the likelihood s/he will switch to a smaller practice or stop practicing medicine altogether. Researchers undertook the study after finding that although 94 percent of doctors never had a malpractice claim during a 10-year span, 1 percent of physicians accounted for nearly 33 percent of all claims. For their findings, the research team obtained data from Medicare and from the National Practitioner Data Bank on practice patterns from 2008 through 2015. Compared to doctors with no claims, the researcher found that the odds of a physician leaving medicine rose 9 percent with one claim, 18 percent with two, 27 percent with three, 37 percent with four and 45 percent with more than four. However, nearly 93 percent with five or more claims kept practicing. Another trend was indeed the shift to a smaller practice. The odds increased 8 percent with one claim, 21 percent with two, 20 percent with three, 46 percent with four and 58 percent with more than four.


The American Medical Association's model checklist to guide physicians considering unwinding an existing contractual relationship with providers cites five key considerations, including the options that are available. A second consideration is the cost for unwinding the arrangement, including new expenses for staff, infrastructure or compliance. A third factor to gauge is patient portability. Issues like data retention and communications to patients about the unwinding of a contract can also help or impede the transition, depending on how well they are managed.

A fourth consideration is contractual provisions, such as noncompete agreements, requiring physicians to exit a market if they are no longer employed or affiliated with a health system, which can be a major pain point when trying to unwind a relationship. Finally, physicians should consider timing, as those who are aware of the contractual, financial and external factors fueling the pressure to unwind a relationship are better positioned to smartly navigate the process.


Growing numbers of patients are becoming empowered to take charge of their health. Empowered patients typically search for health and wellness information on their own, then partner with their physician in deciding the care they need, who should provide it and where. Factors underlying patient empowerment include wider availability of health and medical information online, the popularity of social media and direct-to-consumer pharmaceutical advertising.

Most physicians say they welcome patient empowerment, although one drawback is the risk of finding misleading, incomplete or incorrect information on their own, with provider ratings often cited as a complicating factor. Ultimately, physicians who want to harness this trend in a manner beneficial to patients require the support of trust, communication and patience in the doctor-patient dynamic.


Practices can face serious penalties if their employees can access their electronic health record (EHR) systems. Risk should be addressed with a wide-ranging EHR access policy that includes quarterly employee training and routine audits of employee activity. When possible, practices should flag personal relationships and conflicts, with records of employees' relatives cited and handled by other staff.

Staff should also be properly disciplined for violations, including termination where appropriate. Finally, practices should take heed if employees say they seeing violations or are worried about how the practice is operating or if particular people are doing their jobs properly.

Health Policy and Reimbursement

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Analysis from the JPMorgan Chase Institute found Americans' out-of-pocket healthcare spending spikes about 60 percent in the week after people get their tax refunds, with most spent during face-to-face encounters at medical providers. The implication is that consumers are delaying such expenses until they have cash in hand to get treated. Refunds spur an approximately 10 percent increase in the number of people making in-person healthcare payments on weekdays, and they are often followed by increased cash withdrawals, credit card payments and spending on durable goods.


On April 10, U.S. Sen. Thom Tillis (R-NC) and 17 other Senate Republicans unveiled a narrowly tailored proposal to preserve some of the most popular features of the Affordable Care Act (ACA), including protections for people with preexisting conditions. On the same day, U.S. Sen. Bernie Sanders (I-VT) introduced a bill that would extend government-run health insurance to every American, dubbed Medicare for All. He was joined by several Democratic senators, including Kirsten Gillibrand of New York, Cory Booker of New Jersey, Kamala Harris of California and Elizabeth Warren of Massachusetts. Democratic party leadership generally has focused on proposals to strengthen the ACA, rather than pursue a broad overhaul of the healthcare system.

Medicine, Drugs and Devices

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The U.S. Food and Drug Administration (FDA) has approved romosozumab-aqqg for the treatment of osteoporosis in postmenopausal women at high risk of fracture. One dose of romosozumab-aqqg—a monoclonal antibody that blocks the effects of the sclerostin protein—consists of two injections, one after the other, administered once a month by a healthcare professional. Because the bone-forming effect of the drug wanes after 12 doses, FDA notes that more than 12 doses should not be used. Women who need additional treatment should begin an osteoporosis treatment that reduces bone breakdown.


Members of Congress from both parties have vowed to work together on legislation to prevent more people from dying because they cannot afford insulin. "You've done something here today that we've been trying to do in Congress for years, and that is to create bipartisanship. This is going to end," Rep. Earl "Buddy" Carter (R-GA) said at the end of a hearing with drug industry executives in reference to the arrangements that drive up list prices of insulin and the out-of-pocket costs for many people with diabetes. Rep. Jan Schakowsky (D-IL) concurred, noting that "on both sides of the aisle, there is a commitment" to end price gouging by insulin manufacturers.


Drug pricing advocates celebrated when, with an hour remaining before the 2019 Maryland legislative session expired, lawmakers passed a first-of-its kind law to create a state board that could cap payments for ultraexpensive prescription drugs. Pharmaceutical industry representatives warned that the legislation would leave cancer patients without cutting-edge treatments and would be challenged in court. Even so, barring a veto from the state's governor, the creation of a "drug affordability board," which would take effect in 2022, is one of the most visible manifestations of the nationwide political momentum to bring down high drug costs.