News From ACFAS

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Present your latest discoveries in poster format at ACFAS 2019, February 14–17, 2019 at the New Orleans Convention Center, and be part of an annual tradition that captures the very best in foot and ankle medical research.

Poster abstracts for this year’s competition must be submitted to ACFAS by September 10, 2018 to be eligible for review. PDFs of eligible posters are due November 7, 2018.

Visit acfas.org to view submission guidelines/criteria and to submit your poster now. Get on the right track to help with two of your biggest stresses—finding a residency and managing your student loan debt! Participate in ACFAS’ two free upcoming webinars and have all your questions answered.

The Price of Success: Managing Student Loan Repayment
Thursday, August 30
8pm CDST
Speakers: Nicholas Smith, DPM, FACFAS; Todd Woodlee, Vice President, iGrad

Register Now or For More Information

Residency Director Discussion: Keys to Getting into the Residency of Your Choice
Thursday, September 20
8pm CDST
Speakers: Bryan Sagray, DPM, FACFAS; Mike Vaardahl, DPM, FACFAS

Register Now or For More Information The 2019 Residency Directors Forum will be held in the Big Easy on Wednesday, February 13, 2019 in advance of ACFAS 2019 at the New Orleans Convention Center.

Make this not-to-be-missed event your CPME and hospital requirement for faculty development.

Teaching Research
The field of foot and ankle surgery is in desperate need of evidence-based research, and there is no better place than our own academic institutions and programs to lead such endeavors. This year’s Forum attendees will learn the hottest research topics, discover secrets to research funding and explore ways to incorporate research within a residency curriculum.

Patient Safety
Patient safety has raised the attention of many hospitals and institutions. A risk expert will present on how best to disclose medical misadventures without causing a legal disaster. Patient safety is of the utmost importance, and one of the most difficult tasks for a residency director is managing a challenging resident. The Forum will also teach the ABCs of resident remediation and dismissal.

Access to Organizational Representatives
Finally, back by popular demand, Forum attendees will have one-on-one direct access to representatives from CPME, AACPM, ABFAS, ABPM and PRR.

This is just a taste of the content to be presented at this year’s Forum. Watch your email for more event details and registration info in early fall.

Foot and Ankle Surgery

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Researchers compared postoperative outcomes between conventional simple interrupted nylon sutures and 2-octyl cyanoacrylate as a topical skin adhesive to close the incision after ankle fracture surgery.

They retrospectively reviewed the records of 367 consecutive patients (174 simple interrupted nylon suture patients and 193 topical skin adhesive patients) who underwent operative treatment for ankle fracture between 2010 and 2015. Development of wound complications, operative time, Olerud-Molander Ankle Score (OMAS) and patient satisfaction with the wound were compared.

The researchers found no differences in complication rates or in OMAS at three months or 12 months following surgery between the two types of wound closure. Operative time was nine minutes shorter when topical skin adhesive was used compared with nylon sutures. Patient satisfaction with their wound was significantly higher in the topical skin adhesive group than in the nylon skin suture group.

The researchers concluded that the use of 2-octyl cyanoacrylate topical skin adhesive for wound closure following ankle fracture surgery was effective, safe and showed higher patient satisfaction than simple interrupted nylon sutures. They noted that caution should be taken due to the insufficient statistical power of complications, however.


Peroneus brevis muscle flap is a distinguished, distally based safe flap that can be manipulated to cover small defects in the leg and ankle. For large defects, a more distal, larger flap is required either locally or distantly.

In this study, 42 distally based peroneus brevis muscle flaps were elevated in 42 patients with major lower leg, ankle and proximal foot defects of six to 15 cm in length and six to 12 cm in width. Anatomical findings were recorded as number, size and sources of blood supply, entry sites, the lowermost two arterial supplies, internal distribution of blood supply to the muscle, the relationship between external and internal distribution of the blood vessels, the length of the muscle, the entry site of the main artery and the splitting of the proximal portion of the peroneus brevis muscle to expand its width to sufficiently cover large defects.

The anatomical findings suggested that the muscle can be safely extended to cover a large defect in the leg, ankle or proximal foot. In addition, the longitudinal splitting of the muscle increases its width by up to three times, making it an excellent long-surviving flap to cover a large defect.

The researchers concluded that a distally based peroneus brevis muscle flap has a rich blood supply and safely reaches the proximal foot, with a secure splitting to cover large defects in the leg, ankle and proximal foot.


The aim of this prospective observational study was to examine the incidence of neurologic and peripheral nerve block (PNB) site complications on a busy foot and ankle service that utilizes ankle blocks (ABs) and popliteal blocks (POPs). Researchers assessed patients undergoing foot and ankle surgery with ABs or POPs for complications during postoperative visits at two, six and 12 weeks.

From October 2012 to October 2014, 2516 patients had 2,704 surgeries. Researchers found a total of 195 complications (7.2 percent) considered neurologic or at the PNB site. The incidence of serious complications was 0.7 percent. A higher complication rate was reported for POPs (8.8 percent) than for ABs (2.5 percent). However, when analysis was limited to forefoot surgery, this difference was not significant. Dexamethasone use was associated with increased complications for POPs. Only five of the 195 total complications, and two of 20 serious complications, were considered to have been likely caused by the block by the reviewing surgeon and anesthesiologist.

The researchers concluded that the higher complication rate for POPs using perineural dexamethasone should be interpreted cautiously in light of the lack of randomization and likely confounders.

Practice Management

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In an ever-changing healthcare world, new and seasoned physicians alike should keep some issues in mind to ensure the best chance of prolonged success. First, research shows that as many as two thirds of U.S. physicians feel burned out or depressed, costing hospitals and health systems as much as $1.7 billion annually. Fewer administrative tasks and fewer hours spent working may help alleviate burnout, while clear communication and realistic expectations by employed physician and employer may help ensure a longer and more productive professional relationship.

Meanwhile, payer models of reimbursement continue to evolve nationwide, which may affect a physician's pay. It is important to encourage a physician to maintain excellence while also becoming a better businessperson who understands the challenges and opportunities resulting from changes in payer programs. In addition, employers should embrace newer technologies where clinically advantageous. More junior physicians should be prepared to articulate the benefits of purchasing newer clinical and diagnostic tools.

Furthermore, the Doximity 2018 Physician Compensation Report found that in 2017, "for the first time, more women than men enrolled in U.S. medical schools." However, female physicians were paid less than male physicians. A female doctor should be an advocate for herself to be paid appropriately and a more seasoned physician—male or female—should compensate a "newer" physician fairly and competitively. Finally, rapidly occurring consolidations and new affiliations in the industry can be disconcerting, but physicians must be prepared to embrace the changes and be able to react and respond in a timely manner.


Experienced professionals offer advice for new residents and those just starting jobs at medical practices. One recommendation is to explore career opportunities and to turn to medical societies for help. New practitioners should also do what is best for them: many opportunities for private practice exist, and a hospital or large medical conglomerate may not be the best option for salary, protection or longevity, according to Stephen Rockower of Capital Orthopaedics and Rehabilitation in Maryland.

Furthermore, continue learning. "Don't be too proud or ashamed to ask another physician for advice," advised Melissa Young, MD, of Mid Atlantic Diabetes and Endocrinology Associates. "Look things up if you're unsure. Keep reading and attending conferences." In addition, avoid hubris, and approach things with the attitude that there is a lot left to learn. "It was hard for me to realize that even though I may be at the top of my knowledge game exiting residency, I wasn't the best physician I could be," said Mark Birmingham, Boulder Medical Center/Orthopaedic Department in Colorado.

Another recommendation is to spend time with patients. "The relationships that can be made with patients make every day worth coming to work," said Deborah L. Winiger, of North Suburban Family Healthcare in Illinois. Finally, learn about business. Having some financial intelligence will make you a better doctor who makes more effective decisions, experts say.


Two recent studies indicate that workplace culture plays a more important role in reducing physician burnout than does improving safety protocols or using checklists. One study by researchers at the NYU School of Medicine found that physicians who work in small, independent primary care practices with five or fewer physicians report significantly lower levels of burnout than the national average. Lead author Donna Shelley, MD, said that physicians were asked about the "adaptive reserve" of their practices, which she described as a workplace culture that provides opportunities for growth and the ability to learn from mistakes by talking and listening to each other. Physicians who said they are included in decisions and have control over their work environment reported lower levels of burnout.

Another recent study published by researchers at Stanford University School of Medicine found that physician burnout is at least equally responsible for medical errors as unsafe medical workplace conditions. The researchers surveyed nearly 6,700 physicians in active practice nationwide, and 55 percent reported symptoms of burnout. In addition, 10 percent of the physicians made at least one major medical error during the preceding three months. The study discovered that rates of medical errors tripled in medical work units, even those considered extremely safe, if physician burnout was prevalent. Study lead author Daniel Tawfik, MD, suggested physician burnout may be a bigger cause of medical errors than a poor safety environment. He proposed a two-pronged approach that addresses burnout while also fixing the workplace safety with checklists and better teamwork.

Health Policy and Reimbursement

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U.S. Health and Human Services (HHS) Secretary Alex Azar is pushing for more oversight of hospitals that receive drug discounts under the federal 340B program. "By one estimate, discounted purchases under 340B totaled $16 billion in 2016—a fourfold increase just since 2009," Azar said at the annual meeting of 340B Health, a trade group for 340B hospitals. "This growth has occurred without any increase in statutory oversight."

Azar proposed two types of reforms for the 340B pricing program. First, he wants more transparency regarding how these discounts are being used. In addition, he is calling for reforms to limit the gap between discounted prices and the reimbursement provided, especially by government programs.


The U.S. Centers for Medicare and Medicaid Services (CMS) has proposed compensating doctors for telemedicine and overhauling decades-old Medicare billing standards. In a proposed rule, the agency said it would pay doctors for their time when they contact beneficiaries virtually to determine whether an in-person visit or other service is necessary. "This is a big issue for elderly and disabled population for which transportation can be a barrier to care," CMS Administrator Seema Verma said. "We're not intending to replace office visits but rather to augment them and create new access points for patients."

Most physicians bill Medicare for patient visits under a set of codes that distinguish level of complexity and site of care, known as evaluation and management visit codes, which CMS has used since 1995. The agency has now proposed allowing practitioners to designate the level of a patient's care needs using their medical decisionmaking or time they spent with the patient instead of applying the old documentation guidelines.

In addition, CMS wants to remove the requirement to justify the medical necessity of a home visit in place of an office visit and is considering ending a policy that bars payment for same-day visits with multiple practitioners in the same specialty within a group practice. The proposed rule also includes some major changes to administration of MACRA, including an opt-in option for physicians with a low volume of Medicare Part B enrollees or reimbursements and a waiver for doctors who participate in a new Medicare Advantage demonstration.


The U.S. Centers for Medicare and Medicaid Services (CMS) is working to issue a proposed regulation by year's end that would relax the "Stark law" preventing physician self-referral, said CMS administrator Seema Verma. "One of the barriers around [promoting] value-based care is burdensome regulations, and that's where Stark comes into it," Verma said at a recent briefing sponsored by the Alliance for Health Policy and public relations firm APCO Worldwide. "We are going to do something on Stark—I'm very certain about that—and we hope to have something out by the end of the year."

Verma also discussed CMS's other moves to reduce the regulation burden on providers. The agency had previously announced that it was scrapping some of the current quality measures for home healthcare and dialysis providers. Verma noted that CMS recently conducted a nationwide listening tour and heard about the burden of the reporting. Upon examining all of the measures, they found that many quality measures were "topped out" and many were duplicative. Eventually, "we want to get to a system where we can extract information from medical records, from claims data. That's the overall direction we're going in on quality measurement," she said.

Verma also suggested that CMS might be moving toward "site-neutral" payments, in which all Medicare providers are paid the same for a particular procedure or service regardless of where it was performed.

Medicine, Drugs and Devices

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The U.S. Department of Justice (DOJ) has finalized a proposal to improve the Drug Enforcement Administration (DEA's) ability to control the diversion of dangerous drugs. Under the rule, submitted for publication in the Federal Register, DEA will consider the extent that a drug is diverted for abuse when it sets its annual opioid production limits. "If DEA believes that a particular opioid or a particular company's opioids are being diverted for misuse, this allows DEA to reduce the amount that can be produced in a given year," DEA said.

DEA Acting Administrator Uttam Dhillon noted, "These common sense actions directly respond to the national opioid epidemic by allowing DEA to use drug diversion as a basis to evaluate whether a drug's production should be reduced. This also opens the door for increased communication and better information sharing between DEA and individual states, as we work together to address the opioid problem plaguing our country."

The final rule mandates that DEA share notices of proposed aggregate production quotas and final aggregate production quota orders to the state attorneys general. In addition, DEA said, the rule allows the agency to consider relevant information from the U.S. Department of Health and Human Services, the U.S. Food and Drug Administration, the U.S. Centers for Disease Control and Prevention and the U.S. Centers for Medicare and Medicaid Services, as well as relevant data from the states.


The U.S. Food and Drug Administration (FDA) is working to more aggressively combat drug shortages. In a novel approach for the agency, FDA announced plans for a task force to investigate ways to improve the supply of crucial drugs. The regulator typically cannot act until a drug maker informs it that shortages are imminent or that it will halt production of a drug. FDA Commissioner Scott Gottlieb said the agency will ask Congress for the authority to allow it to intervene, citing a recent letter from about 200 lawmakers urging changes and offering support.

Most drug shortages involve low-profit generic pills and injections that are commonly used by hospitals. Many are made by only a few companies, so when production problems occur, the few other drug makers cannot fill the gap. Currently, FDA inspectors can work with a manufacturer to rapidly address quality problems that have shut down production. The agency also works to find alternate suppliers and to expedite approval for them to sell that medicine. A hearing is slated for the fall to get input from stakeholders.

A key issue, Gottlieb said, is that generic drug makers are increasingly paid by middlemen at rates barely above their production costs. He said finding ways for the Veterans Administration, Medicare and Medicaid to pay slightly more for the most crucial medicines could influence private insurers to do the same.


The Trump administration's tariffs on Chinese imports will cost U.S. medical device manufacturers more than $138 million this year, according to an estimate by the Medical Imaging and Technology Alliance (MITA). As a result, the group is requesting that medical imaging technology and devices be exempt from the tariffs. The 25 percent tariffs that went into effect June 6 affect MRIs, pacemakers and sonograms, among other medical devices.

The tariffs could force some vendors to downsize and slash research and development budgets, according to a recent MITA survey. CT scanners and other X-ray device components will face the worst blowback, the survey found. Part of the issue, MITA argued, is that many medical device products are imported from a Chinese manufacturing facility to the United States, where the devices are transformed and then reexported. Taxing on both ends will "create a disincentive," it said. "Policymakers should act quickly to ensure that patient access to innovative life-saving technology is not compromised," said Patrick Hope, MITA executive director.