News From ACFAS

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We’re packing up and shipping out! ACFAS is ready to bring you a new On the Road series this fall to show you that when you work “In the Trenches” together with your colleagues, no surgical challenge is too great.

This two-day seminar kicks off on Friday night with the presentation, “Controversies and Complications,” followed by a candid panel discussion and refreshments. Bring your own work cases with you for review and insight from panelists and your fellow attendees.

Continue your learning on Saturday with interactive lectures covering surgical approaches, foot fixation options and how to choose the right surgical treatment for each patient. Put your skills to the test in two sawbones labs then close out the seminar with faculty’s practical “Tips, Tricks and Quips” you can use as soon as you get back to the office.

Visit acfas.org/ontheroad to register now, and we’ll see you on the road soon! Don’t have plans for Thursday night? You do now! Take advantage of a free webinar from ACFAS, and get on the right track to help with one of your biggest stresses—managing your student loan debt.

This hour-long webinar will cover best practices to obtain and effectively manage student loan repayment from the initial financial commitment, during your education and once you are finally being compensated as a practicing physician. There will be plenty of time for open Q&A at the end of the presentation.

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! Advanced imaging helps you identify injury and infection in the foot and ankle and also track healing, but are you taking full advantage of this technology in your practice? Check out ACFAS’ latest free Clinical Session, “Improving Your Image: Advanced Imaging of the Foot and Ankle (YMR),” to learn how to better interpret images when evaluating nonunions, osteochondral lesions, osteomyelitis, torn ligaments and more.

Presentations in this newest release include:

• Osteomyelitis: What’s Better Than a Bone Scan?
• Is the Ligament Torn or Not? I Can’t Tell
• Identifying Tendon Pathology Through Advanced Imaging
• Osteochondral Lesions
• Identification of Nonunions and Malunions

Complete a short CME exam after you watch the presentations to earn 1.25 continuing education hours. Visit the ACFAS e-Learning Portal for this and other Clinical Sessions plus monthly podcasts, Surgical Techniques videos and e-Books to take your learning to the next level.

Foot and Ankle Surgery

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Although a range of surgical procedures for lateral ankle ligament reconstruction have been reported, little is known about the effects of initial graft tension. The purpose of this study was to investigate the effects of initial graft tension in calcaneofibular ligament (CFL) reconstruction. It was hypothesized that a high degree of initial graft tension would cause abnormal kinematics, laxity and excessive graft tension.

Twelve cadaveric ankles were tested with a six-degrees-of-freedom robotic system to apply passive plantarflexion-dorsiflexion motion and multidirectional loads. A repeated-measures experiment was designed with the CFL intact, CFL transected and CFL reconstructed with four initial tension conditions (10, 30, 50 and 70 N). The three-dimensional path and reconstructed graft tension were simultaneously recorded.

The calcaneus in CFL reconstruction with an initial tension of 70 N had the most eversion relative to the intact condition. The calcaneus also moved more posteriorly with external rotation as the initial tension increased. The reconstructed graft tension tended to increase as the initial tension increased.

The researchers concluded that ankle kinematic patterns and laxity after CFL reconstruction tended to become more abnormal as the initial graft tension increased at the time of surgery. Moreover, excessive initial graft tension caused excessive tension on the reconstructed graft. This study highlighted the importance of initial graft tension during CFL reconstruction. Overtensioning during CFL reconstruction should be avoided to imitate a normal ankle.


When surgery is indicated for hallux rigidus, toe arthroplasty is an alternative procedure to arthrodesis for patients who seek to preserve toe range of motion. This study investigated midterm outcomes of first metatarsophalangeal joint (MTPJ) arthroplasty to determine whether partial or total joint replacement confers benefit in these patients.

A systematic review of MTPJ arthroplasty was performed from 2000 to 2017. A Forest plot was created comparing preoperative and postoperative American Orthopedic Foot and Ankle Score (AOFAS), Visual Analogue Scale (VAS) and range of motion (ROM) results for both hemitoe and total-toe arthroplasty. Statistical analysis was performed.

Mean postoperative AOFAS scores in patients undergoing hemiarthroplasty improved by 50.7 points, while the mean AOFAS scores in total joint arthroplasty patients improved by 40.6 points. VAS outcomes were comparable. Mean postoperative MTPJ ROM improved by 43.0° in hemitoe patients, which exceeded the mean ROM improvement of 32.5° found in total joint arthroplasty cases. A meta-analysis revealed no significant difference.

The researchers concluded that hemisurface implants in MTPJ arthroplasty may improve postoperative AOFAS and ROM results to a greater extent than total-toe devices.


Limited information exists regarding the outcomes of operative treatment for ankle instability with coexisting arthritic changes in the medial gutter. This study was performed to evaluate the intermediate-term clinical and radiological outcomes following a modified Broström procedure and arthroscopic debridement in middle-aged patients with combined medial gutter osteoarthritis and chronic ankle instability.

Researchers followed 22 patients with medial gutter osteoarthritis related to chronic lateral ankle instability for more than three years after operative treatment. All patients showed medial joint space narrowing of Takakura stage II at the time of surgery. The clinical evaluation consisted of the American Orthopaedic Foot and Ankle Society (AOFAS) score, visual analog scale (VAS) for medial ankle pain during walking and Foot and Ankle Ability Measure (FAAM).

Mean AOFAS and FAAM scores significantly improved from 51.2 and 45.7 points preoperatively to 80.3 and 78.4 points at final follow-up, respectively. Although mean pain-VAS significantly improved from 6.8 points to 3.5 points, eight patients complained of gait discomfort with considerable pain of four or more points. Only one patient had recurrent ankle instability while six patients showed a progression of arthritis stage.

The researchers concluded that modified Broström procedure combined with arthroscopic debridement appears to be an effective operative option for medial gutter osteoarthritis secondary to chronic ankle instability. Despite the onset of arthritis, most patients were able to achieve significant improvement in reducing pain while eliminating instability.

Practice Management

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Between 2011 to 2014, physician burnout increased from 45.5 percent to 54.4 percent, according to researchers at the University of California, Riverside School of Medicine. They identified three major factors that contribute to this trend. First, the doctor-patient relationship has been overtaken by an insurance company-client relationship, setting limitations on the treatment that doctors can provide to the insurance company's members. In addition, feelings of cynicism prevail, resulting from patients no longer expecting continuity of care and regularly changing doctors. The third factor the authors detailed is a general lack of enthusiasm for work.

The researchers compared data on physician burnout and satisfaction with work-life balance over the three-year period. They found that physician burnout was highest in emergency medicine, family medicine, internal medicine and pediatrics. They also suggested that four transformational medical practice events that occurred between 2011 and 2014 contributed to the increase in physician burnout: mandated electronic health records (EHRs), hospital purchases of medical groups, escalating drug prices and the Affordable Care Act.

EHRs are perhaps the biggest contributor, researchers said. They typically lead to less time with patients and more time in front of computers, decreasing doctors' level of happiness and satisfaction in their jobs. Other EHR-related issues include HIPAA-restricted access to outside records, time at home finishing EHR records and unreadable cloned patient notes. The authors recommend that EHRs not be the focus of a patient's visit. Practices should also reject EHRs that tie up doctor-patient time, as well as ones that use billing diagnoses instead of patient assessments.


Through effective workflow optimization, practices can create a team-based approach to care that combats physician burnout, according to Richard Furlong, MD, an internist with Virginia Mason Medical Center in Seattle. Inefficient workflows contribute to burnout in several ways, he says, from having visits not set up to "mismatch of supply and demand and poor skill-task alignment." Furlong and his colleagues have focused on three workflow optimization tactics that foster teamwork: spreading the work burden among physicians, adoption of standardized work roles and colocation of team members.

To prevent physicians from burning out, patients in Furlong's practice are often seen by other caregivers, such as clinical pharmacists, registered nurses or physician assistants. Clinical pharmacists are especially helpful in easing physician workloads, Furlong says, and most primary care practices could benefit from utilizing them. In addition, establishing standardized roles can ease the workload burden on physicians. For example, Furlong's practice has established new standardized roles to limit the number of patient portal and phone messages that are handled directly by physicians. Finally, having care team members located at the same site can enable workflow optimization and lighten physician workload, Furlong says.

A survey by The Advisory Board found that the workflow optimization efforts are having a positive impact on the employment satisfaction of staff at Virginia Mason Kirkland Medical Center, where Furlong is based. For the past two years, 100 percent of staff surveyed have said they were engaged or content with their workplace.


Modern practices can refresh their referral building using the Three A's of medicine: Availability, Affability and Ability. The first step is capturing and tracking referral data accurately. This is the baseline of any effective referral building strategy, but it is often overlooked. For example, develop detailed referral categories, such as "Edwina Jones, MD," not "Doctor." Create a protocol for how new categories are added so busy staff does not end up overutilizing "Other," which will skew the data. Generate quarterly reports and review referral sources.

In addition, expand availability using technology. For example, you might offer access to secure text messaging or the physician social network Doximity as a way for referrers to connect about patients. Third, deliver patient experiences that result in positive feedback. This is more important than ever in the age of online review sites and value-based care arrangements.

Furthermore, since patients will typically focus more on the experience and convenience over "quality," verify and promote your online clinical quality indicators. Make sure your scores on Healthgrades, Physician Compare and payer sites are accurate, and use positive scores and reviews in your referral building and social media efforts. Finally, do not let referral relationships lapse. People are busy, and referring practice staff may leave their roles. Take time each quarter to cultivate relationships with physicians, patients and influencers so they do not go stale, even by something as simple as sending handwritten thank you notes.

Health Policy and Reimbursement

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The U.S. Food and Drug Administration (FDA) has contracted the National Academies of Sciences, Engineering and Medicine (NASEM) to help advance development of evidence-based guidelines for appropriate opioid analgesic prescribing for acute pain. FDA Commissioner Scott Gottlieb said NASEM will undertake a study and disclose its findings, starting with identification and prioritization of "procedures and conditions associated with acute pain for which opioid analgesics are commonly prescribed and where evidence-based clinical practice guidelines would help inform prescribing practices." He noted that analyses "suggest that the first prescription for many common, acute indications could typically be for many fewer pills."

NASEM will also examine current opioid analgesic prescribing guidelines to investigate how they were developed, detect any gaps and outline studies needed to generate evidence. Gottlieb said the guidelines would differ from corresponding work by the U.S. Centers for Disease Control and Prevention as they would be indication-specific and based on evidence taken from assessments of clinical practice and pain treatment. NASEM will also organize meetings and public workshops to engage various stakeholders who can contribute on existing guidelines and on emerging evidence or specific policy issues related to the development and availability of opioid analgesic prescription guidelines.


The U.S. Government Accountability Office (GAO) has released a report stating that the Trump administration needs to step up its management of sign-up seasons under the Affordable Care Act but also praised some of its efforts. On one hand, the nonpartisan watchdog discovered issues with consumer counseling and advertising and recommended basic fixes, such as setting enrollment targets. On the other hand, it applauded administration actions that helped people enroll, including a more reliable HealthCare.gov website and reduced call center wait times.

The report found that the U.S. Health and Human Services Department (HHS) broke with its previous practice by failing to set enrollment targets for last year. The watchdog recommended that HHS resume setting goals, a standard management tool for government agencies. The report also found that HHS used "problematic" data to justify a 40 percent cut in funding for enrollment counseling programs known as Navigators. In addition, when HHS reduced money for open-enrollment advertising by 90 percent, officials said they were doing away with wasteful spending, but an internal study by the department had found paid television ads were one of the most effective ways to enroll consumers.

HHS said that the 2018 enrollment season was the "most cost-effective and successful experience" for consumers, citing a 90 percent customer satisfaction rate with the HealthCare.gov call center. GAO found that sign-ups in the 39 states served by HHS through the federal HealthCare.gov website fell by 5 percent last year, while states running their own enrollment effort maintained their sign-up levels.


The Trump administration is weighing a proposal to require pharmaceutical companies to be more transparent about their pricing. The U.S. Office of Management and Budget (OMB) has received a proposed regulation by the U.S. Department of Health and Human Services (HHS) related to drug pricing transparency in the Medicare and Medicaid systems.

Meanwhile, Senators Chuck Grassley (R-Iowa) and Dick Durbin (D-Ill.) have proposed an amendment to an HHS spending bill that would require drugmakers to post prices in direct-to-consumer advertising. The senators say the amendment would bring more transparency. Listing prices in drug ads is a part of President Trump's blueprint to lower drug prices.

"While we cannot comment on pending regulations, the president's 'American Patients First' blueprint to lower prescription drug prices and reduce out-of-pocket costs clearly states that HHS is looking at options to require drug pricing transparency," said Caitlin Oakley, a spokeswoman for the agency.

The Pharmaceutical Research and Manufacturers of America argued that revealing prices in ads will not benefit consumers because they are not what patients will pay at the pharmacy. The industry group also said the requirement could face legal issues, "including First Amendment concerns."

Medicine, Drugs and Devices

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Medical device firm managers may rely on physicians to uncover product defects instead of issuing a recall, according to a study published in the Journal of Operations Management. The research is the first behavioral study using actual industry managers to study what influences voluntary product recall decisions. The findings have drawn attention from the U.S. Food and Drug Administration (FDA), which expressed interest in using this research to improve how it oversees medical device product quality.

A key finding of the study is that "medical device industry managers appear to trust physicians to screen out defects on behalf of the firm, meaning that when the defect is detectable to the physician, managers are less likely to recall," said lead author George Ball. "This is because of a perception of increased patient safety when defects are detectable." The study also found that some managers hesitate to recall a product until they understand the root cause of the defect because this can reduce recall costs to the firm.

"The decision to recall a product can significantly affect an operations manager's career, the credibility and financial performance of the firm and the safety of customers," the authors wrote. "Surprisingly, FDA does not clearly specify how a manager should integrate the multiple, and potentially conflicting, criteria influencing whether or not to recall a product. Consequently, managers use individual judgment in arriving at recall decisions."


Cinematically rendered images based on CT scans of the ankle are more photorealistic and present relevant findings better than conventional volume-rendered 3D reconstructions, according to a recent study published in the American Journal of Roentgenology. Cinematic rendering is an advanced visualization method involving complex lighting models that simulate light and shadow to photorealistically display the anatomical structures of CT scans. Researchers from Switzerland acquired the imaging data of 10 patients who underwent CT exams for different types of ankle injuries. They reconstructed the CT datasets as 3D images using a conventional volume-rendering technique and a cinematic-rendering technique. After randomizing both sets of images, the researchers presented the 3D images to 12 radiologists and 10 orthopaedic surgeons for subjective evaluation.

Overall, the physicians believed the cinematically rendered images offered the best visualization for most of the 10 ankle injuries. The physicians' preference for cinematically rendered images stemmed from various advantages of the technique over conventional volume rendering, including realistic shadowing, depth-of-field effects and perception of soft tissue. However, there were a few injuries—mainly those not involving fractures—for which the physicians preferred conventional volume-rendered images or considered both imaging techniques equally as good. The authors noted two drawbacks to cinematic rendering: the potential for realistic shadows to hide certain parts of images, such as fracture gaps, that are usually well lit in standard reconstructions, as well as a long processing time.


Nationwide, states are forcing pharmaceutical companies to disclose and justify price hikes. The drug manufacturers, in turn, are challenging the state laws as a violation of their constitutional rights. The bipartisan efforts by states come as the White House is pressuring drug companies to freeze prices and slash out-of-pocket costs for consumers struggling to pay for drugs. Twenty-four states have passed 37 bills in 2018 to curb rising prescription costs, reports Trish Riley, executive director of the National Academy for State Health Policy.

Under a new Connecticut law, for instance, drug companies must justify price increases for certain drugs if the price rises by at least 20 percent in one year or 50 percent over three years. Additionally, the middlemen, known as pharmacy benefit managers, must disclose the amount of rebates and other price concessions they receive from drug companies.