News From ACFAS

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Put your latest breakthroughs front and center at ACFAS 2019 in New Orleans by submitting your manuscript to the College’s annual manuscript competition.

Set for February 14–17, 2019 at the New Orleans Convention Center, the competition brings together the best in foot and ankle surgical research and provides a clear snapshot of where the profession is headed. All manuscripts submitted for consideration are blind-reviewed and judged on established criteria. Winners divide $10,000 in prize money.

Entries for the 2019 competition are due August 15, 2018. Check acfas.org during the summer for submission guidelines and criteria. Do you have an exciting patient success story to tell? If so, we want to hear it! ACFAS is looking to share these compelling stories, and any other news of innovative or “first-of-its-kind” surgeries you’re performing, with the national media to help raise awareness of the important work you do.

Contact Melissa Matusek, CAE, ACFAS Marketing and Communications director, at (773) 444-1306 to share your patient story, and watch This Week @ ACFAS for updates on the College’s national public relations campaign. Stay ahead of your yearly licensure and privileging requirements with the ACFAS e-Learning Portal. Always ready when you are, the portal features an extensive collection of Clinical Session videos, Podcasts, Surgical Techniques DVDs, e-Books and more to help you earn CME hours.

New resources are added to the e-Learning Portal every six months, and each tool in the portal includes an exam you can complete and submit to obtain your CME. Visit acfas.org/e-learning now to explore our latest products and get one step closer to meeting your requirements for the year.

Foot and Ankle Surgery

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Predicting wound healing in patients with critical limb ischemia (CLI) is an ongoing issue. Indocyanine green angiography (ICGA) has the potential to provide regional perfusion information lacking in other methods. Researchers conducted a study to demonstrate successes of a revascularization procedure in CLI patients based on ICGA data. A total of 47 patients undergoing a lower limb revascularization procedure were included in this study. ICGA with intravenous 0.1 mg/kg of 0.1 percent indocyanine green dye was performed pre and post revascularization procedure. ICGA data maximum unit, blush time and blush rate was compared between pre- and post-revascularization data, along with ankle-brachial index (ABI) and transcutaneous oxygen pressure (TCPO2). Out of 47 patients, 43 underwent endovascular revascularization, and four underwent open procedure. Thirty-seven patients' ulcers healed completely on follow-up, with significant improvement in pre- and postoperative ABI, TCPO2 and ICGA data observed. Ten patients' ulcers did not heal in the follow-up period. In those 10 patients, pre- and postoperative ABI and TCPO2 improved, but ICGA data did not improve postoperatively.


Researchers at the University of Alabama, Birmingham conducted a study to examine the incidence of venous thromboembolism (VTE) and to identify risk factors in a large sample of patients receiving orthopaedic foot and ankle surgery. VTE is a rare and potentially deadly complication after orthopaedic foot and ankle surgery, but the true incidence of VTE after surgery stratified by specific procedure has yet to be examined. The researchers retrospectively analyzed data from the National Surgical Quality Improvement Program 2006–2015 data files. The incidence of VTE was calculated for 30 specific orthopaedic foot and ankle surgeries and for four broad types of foot and ankle surgery. Demographic, comorbidity and complication variables were analyzed to determine associations with development of VTE. The overall incidence of VTE in the study sample was 0.6 percent. The types of procedures with the highest frequency of VTE were ankle fractures (105/15,302 cases, 0.7 percent), foot pathologies (28/5,466, 0.6 percent) and arthroscopy (2/398, 0.5 percent). Female gender, increasing age, obesity, inpatient status and nonelective surgery were all significantly associated with VTE. The researchers concluded that although VTE after orthopaedic foot and ankle surgery is rare, several high-risk groups and procedures may be especially indicated for chemical thromboprophylaxis.


The clinical significance of a supplemental saphenous nerve block for major ankle surgery has never been determined in a prospective, randomized, double-blind placebo-controlled trial. Researchers hypothesized that a saphenous nerve block in conjunction with sciatic nerve block reduces the proportion of patients experiencing significant clinical pain after major ankle surgery. Eighteen patients were enrolled and received a popliteal sciatic nerve block. Patients were randomized to single-injection saphenous nerve block with 10 mL 0.5 percent bupivacaine with 1:200,000 epinephrine or 10 mL saline. Primary outcome was the proportion of patients reporting significant clinical pain, defined as a score greater than three on the numerical rating scale. Secondary outcomes were maximal pain and analgesia of the cutaneous territory of the infrapatellar branch of the saphenous nerve. Eight of nine patients in the placebo group reported significant clinical pain, compared to one of nine patients in the bupivacaine-epinephrine group. Maximal pain was significantly lower in the active compared with the placebo group. Breakthrough pain from the saphenous territory began within 30 minutes after surgery in all cases. Sensory testing of the cutaneous territory of the infrapatellar branch of the saphenous nerve showed correlation between pain reported in the anteromedial ankle region and the intensity of cutaneous sensory block in the anteromedial knee region.

Practice Management

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Pharmacists can be a vital addition to primary care practices by addressing barriers to medication adherence, Hae Mi Choe, PharmD, said at the American College of Physicians' annual meeting. Choe's institution, the University of Michigan Medical Group in Ann Arbor, has 11 embedded pharmacists and two PGY-2 ambulatory care specialty residents who provide care across 14 primary care clinics. The pharmacists are trained in motivational interviewing so they can learn why a patient is being nonadherent and can recommend strategies to improve. In addition, the pharmacists have full access to patients' electronic health records, possess special credentialing privileges enabling them to prescribe medications and provide medication management to achieve therapeutic goals. They also conduct "Comprehensive Medication Reviews" and do proactive outreach, which entails searching the medical group's disease registries for patients who are not taking their medications and scheduling 30-minute visits to better understand their adherence barriers. One thing the pharmacist group worked on was increasing the percentage of the medical group's 30,000 primary care patients with hypertension who had their blood pressure under control. Through efforts that included follow-up with pharmacists, Choe said the group was able to improve that percentage from 72 percent to 76 percent. Physician support is essential, according to Choe. "None of this is possible unless physicians embrace pharmacists in the practice," she said.


The Joint Commission has issued an alert warning healthcare facilities to take seven steps to address workplace violence. It argues that hospitals need to more clearly define what constitutes violence, better support victims and enhance prevention initiatives. The moves are recommendations, but employers must take action if an employee faces violence, a Joint Commission spokeswoman said. If the Joint Commission receives complaints, it would consider whether an on-site survey is needed, and an unsatisfactory survey can affect accreditation status. Experts say the healthcare industry has a poor reputation for addressing violence against its employees, which has created problems with morale and retention. Hospitals are working to address the matter both individually and together, according to Melinda Hatton, the American Hospital Association's (AHA) senior vice president and general counsel. Noting that AHA's Hospitals Against Violence initiative is a tool available to hospitals, Hatton said, "The Joint Commission's newest Sentinel Event Alert may provide an additional resource for hospitals on addressing workplace violence, namely physical and verbal violence and its impact on employee morale, retention and well-being." Some healthcare leaders have called for a shift in workplace culture to adopt a zero-tolerance mindset that diminishes barriers to reporting, while others have demanded stiffer legal penalties for people who harass healthcare providers at both the federal and state level.


A STAT analysis of federal inspection data finds that a wide gap exists in the quality of training at teaching hospitals, demonstrated by how frequently these hospitals are cited for deficiencies by the U.S. Centers for Medicare and Medicaid Services. While most of the approximately 1,200 teaching hospitals received no citations between 2014 to 2017, others received dozens of safety violations in that time period—putting patients at risk and compromising the training that residents receive. Teaching hospitals are making some positive changes, and according to the analysis, that has driven down the average number of violations per teaching hospital to its lowest point in three years. But experts worry that the remaining mishaps mean that America's future doctors are not always being prepared to practice medicine safely. Some experts say that "pernicious old-school culture" still pervades much of medical education and champions minimal oversight of trainees, in addition to the belief that learning happens through making mistakes. In 2012, the Accreditation Council for Graduate Medical Education stepped up its oversight policies by conducting mandatory site visits to "increase awareness of residents in formal patient safety activities," such as reporting medical errors or participating in debriefs of those errors after the fact. Some teaching hospitals are taking matters into their own hands. At the University of Chicago Medical Center, every resident must undergo patient safety training, and they are also strongly encouraged to report adverse patient events or "near misses."

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services' (CMS) Center for Medicare and Medicaid Innovation is soliciting feedback on the creation of a program that allows providers to contract directly with patients for care, sidestepping insurers and the Medicare program, in a new request for information. Under one scenario outlined by CMS, a medical practice could receive a lump sum payment from Medicare for each patient to cover basic primary care services, with a chance to earn bonuses from CMS for additional care or quality. The model would give doctors the alternative of avoiding claims submission. Responses are due May 25.


The U.S. Centers for Medicare and Medicaid Services (CMS) has outlined new changes in its proposed annual inpatient hospital rule, including urging hospitals to disclose their prices to patients and an overhaul of the meaningful use program. If the rule is finalized, CMS predicts hospitals will get $4.1 billion more in Medicare inpatient funding next year, compared to last fiscal year's $2.4 billion. The rule is open to comments until June 25. CMS already requires hospitals to either publicly list their standard charges or disclose them upon request, but the agency now says hospitals must post this information. It is unclear whether CMS has the legal authority to make this change, or how difficult implementation could be given the technical nature of hospital billing practices. The agency also wants to overhaul the meaningful use program—which it is renaming "promoting interoperability"—to better highlight measures that require the exchange of health information between providers and patients and give providers incentives to make it easier for patients to access their medical records electronically. The proposed rule specifically encourages the use of application programming interfaces. In addition, CMS proposes eliminating the so-called 25 percent rule, which would reduce Medicare reimbursement rates for long-term care hospitals, and scrapping 19 quality measures that hospitals must report.


The Trump administration says it plans to roll back a rule issued by President Barack Obama that prevents doctors, hospitals and health insurance companies from discriminating against transgender people. The rule was adopted in 2016 to carry out a civil rights law embedded in the Affordable Care Act that prohibits discrimination based on race, color, national origin, sex, age or disability in "any health program or activity" that receives federal financial assistance. The Obama administration said the rule covered "almost all practicing physicians in the United States" because they accept some form of federal remuneration or reimbursement. It applies, for example, to hospitals that accept Medicare and doctors who receive Medicaid payments, as well as to insurers that participate in health insurance marketplaces. Trump administration officials said they believed they had to modify the rule because a federal judge in Texas had found that parts of it were unlawful. The judge temporarily stopped enforcement of the protections for transgender patients, saying that Congress had outlawed discrimination based on sex—"the biological differences between males and females"—but not transgender status.

Medicine, Drugs and Devices

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In an effort to improve the cybersecurity of medical devices, the U.S. Food and Drug Administration (FDA) is planning to establish a "go-team" to investigate suspected incidents of compromise. The devices present acute cybersecurity challenges given that the machines and equipment can have a lifespan of up to 20 years, and healthcare providers may lack the funding and personnel to update them. Also, in some cases, connected medical devices are given to patients who may not realize they need to be updated if a threat is discovered. According to FDA Commissioner Scott Gottlieb, MD, the agency is requesting additional authority from Congress to require manufacturers to make their devices patchable and require hospitals to set up programs to enable security researchers to contact them if they uncover a vulnerability. "Our aim is to make sure that the new advances in technology that are enabling better capabilities and benefits are also harnessed to bring added assurances of safety," Gottlieb said. The go-team, called the CyberMed Safety Analysis Board, would include experts in hardware, networking and biomedical engineering and would work with device manufacturers and FDA to assess vulnerabilities, adjudicate disputes and investigate security issues.


A new technology developed by University of Wisconsin–Madison engineers could one day help tell whether tendon injuries are sufficiently healed for people to resume activities. The researchers developed a new approach for noninvasively measuring tendon tension while a person is engaging in activities like walking or running. The noninvasive device is placed on the skin over a tendon, enabling the assessment of tendon force by examining how the vibrational characteristics of the tendon change when it undergoes loading, as it does during movement. The new system includes a mechanical device that lightly taps the tendon 50 times per second, with each tap setting off a wave in the tendon. Two miniature accelerometers determine how quickly the wave travels. By measuring how muscles and tendons behave within the human body, the technology could improve treatments for musculoskeletal diseases and injuries.


The Senate Health Committee has unanimously voted to send the panel's bipartisan opioid bill to the chamber's floor. The panel held seven hearings on the opioid crisis, including one on the discussion draft of the bill introduced by Health Committee Chairman Lamar Alexander (R-Tenn.) and ranking member Patty Murray (D-Wash.). "The challenge before us has sometimes been described as needing a moonshot," Alexander said during the markup. "I believe that solving the opioid crisis might require the energy of a moonshot, but ultimately, it's not something that can be solved by an agency in Washington, D.C." The bill includes more than 40 proposals from 38 different senators. Specifically, it includes measures that attempt to make it easier to prescribe smaller packs of opioids for limited durations, spur the development of nonaddictive painkillers and bolster the detection of illegal drugs at the border.