News From ACFAS

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This past spring, ACFAS conducted a Compensation and Benefits Survey as part of the College’s triennial Practice Economics and Insights Survey.

Survey results indicate that members of all ages, years of residency and years in practice have seen salary increases over the past three years. Members’ average annual salary (7.8 percent) and share of profit from practice (27 percent) have increased since 2015, with those with four or more years in residency, those with a fellowship and those working in an orthopaedic practice seeing the highest salaries.

Average annual salary is higher among members 36 to 65 years old and among those who had spent two years in residency or who were certified in reconstructive rearfoot/ankle surgery.

Visit acfas.org/compensation to view the complete survey data. Attention residents! Your ACFAS membership will expire on October 1. Renew by September 30 for just $121 and continue receiving:

• Discounts on ACFAS CME offerings, including conferences, courses and e-Learning
• The Journal of Foot & Ankle Surgery, Student & Resident Update, ACFAS Update and This Week @ ACFAS
• Full access to acfas.org and the PodiatryCareers.org career center
• Regional support through ACFAS Region activities and Region funding support for resident manuscripts and posters

Pay online or fax the invoice you received by mail or email with your payment information to (773) 693-9304.

Remember, first-year residents (PGY-1) receive a complimentary year of membership during their first year of residency courtesy of ACFAS and its Regions. Second-year (PGY-2) and third-year (PGY-3) residents must pay the annual dues. While some residency programs may pay for annual dues, it is not done automatically.

Questions about your resident membership? Contact ACFAS Membership Manager Jessica Brown. You read ACFAS' monthly Scientific Literature Reviews (SLRs) to quickly stay up to date on the latest developments in foot and ankle surgery. Take SLRs one step further by using them as references when working on your own surgical cases or as talking or teaching points when meeting with colleagues and patients. SLRs can also serve as a springboard for your own research ideas.

Written by podiatric surgical residents, SLRs are short, digestible summaries of studies from leading medical journals and include podiatric relevance, methods, results and conclusions.

Read the September SLRs now at acfas.org/SLR and also browse the SLR archive for studies dating back to 2009.

Foot and Ankle Surgery

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The goal of this study was to assess the results of open reduction and internal fixation through the extended lateral approach (ELA) for displaced intra-articular calcaneal fractures and to determine whether this approach should remain part of standard therapy.

This retrospective cohort study included 60 patients with 64 displaced intra-articular calcaneal fractures who underwent surgical treatment through the ELA. Outcome measures were the visual analog scale foot and ankle (VAS FA), the American Orthopedic Foot and Ankle Society (AOFAS) score, surgical site infections (SSIs) and reoperations. The mean VAS FA score was 61.0 ± 23.4, and the median AOFAS score was 83, with 55 percent good to excellent scores. The researchers also found 10.9 percent superficial SSIs successfully treated with antibiotics. A deep SSI was diagnosed in 4.7 percent of patients, where premature implant removal was necessary. Patients with an SSI did not have significantly lower VAS FA or AOFAS scores compared to patients without an SSI. Implant removal in absence of SSIs was necessary in 17 patients because of pain, and three patients required secondary arthrodesis because of persistent pain.

The researchers concluded that the ELA proved to be a safe procedure and that the most common complications did not influence the long-term patient outcomes. However, recent literature demonstrates that less invasive techniques appear superior to the ELA with respect to wound complications.


Malunion of a medial impacted ankle fracture may cause varus ankle deformity. This retrospective study examined the use of supramalleolar osteotomy combined with an intra-articular osteotomy in patients with malunited medial impacted ankle fractures.

Twenty-four patients with malunited medial impacted ankle fracture were treated between January 2011 and December 2014. Using Weber's classification, 10 patients had type A fractures and 14 had type B. With the AO classification, 20 patients had 44A2 and four had 44B3. All patients had varus ankle deformity. Supramalleolar osteotomy combined with an intra-articular osteotomy was performed. The visual analog scale (VAS) for pain during daily activities, the Olerud and Molander Scale and the modified Takakura classification stage were used to determine the clinical outcomes and a radiographic analysis was performed.

The radiographic parameters, including the tibial ankle surface (TAS) angle and talar tilt angle (TTA), showed significant differences between the preoperative and follow-up assessments. The mean tibial lateral surface (TLS) did not show a significant change. The average Olerud and Molander Scale score improved significantly from 56.4 ± 6.21 preoperatively to 77.0 ± 6.11 at the latest follow-up. The mean VAS decreased significantly from 6.7 ± 0.8 preoperatively to 3.1 ± 0.6 at the latest follow-up. No significant difference in the modified Takakura classification stage was observed between the preoperative assessment and the last follow-up.

The researchers concluded that the use of a supramalleolar osteotomy combined with an intra-articular osteotomy was an effective option for the treatment of malunited medial impacted ankle fractures associated with varus ankle deformity.


The purpose of this study was to evaluate the outcomes of local intrinsic muscle flaps in the surgical reconstruction of foot and ankle wounds in patients living with diabetes.

A systematic review of the literature was conducted by three independent reviewers using several databases and search engines and over a dozen search terms. Studies meeting the following criteria were included: English language studies, studies published from 1997 to 2017, patients with diabetes treated for foot and/or ankle wounds, use of local intrinsic muscle flaps, follow-up period of six months or more postoperatively, documentation of healing rates, complications and need for revisional surgery. Studies that were entirely literature reviews, descriptions of only surgical technique and/or cadaveric studies and patients without diabetes were excluded.

A total of 13 selected studies met the inclusion criteria and were used for data extraction from a total of 113 patients in which 92 local intrinsic muscle flaps were performed for diabetic foot and/or ankle reconstruction, of which 80 muscle flaps demonstrated success, while 12 flaps encountered complications.

The researchers concluded that although local intrinsic muscle flaps demonstrated a relatively high success rate when used for the definitive closure of certain diabetic foot and ankle wounds based on existing evidence, the systematic review emphasizes the need for more high-quality, larger comparative studies to investigate their efficacy and failure rates in diabetic foot and/or ankle reconstruction.

Practice Management

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According to the Association of American Medical Colleges (AAMC), the United States could see a shortage of up to 120,000 physicians by 2030. The number of students graduating from medical school is in fact increasing, up 27.5 percent from 2002 to 2016; but the number of available residency slots is lagging behind, rising just 8 percent in the same period. If new medical school graduates cannot place into residencies, they are unable to practice, offering no relief to the shortage.

AAMC supports increased funding for graduate medical education, saying it will result in more resident physicians. Several medical associations argue that the current cost of training needs to be determined—per-resident funding is still based on 1980s data—and the two distinct funding streams need to be consolidated into one. Then the system should be structured to respond to physician workforce demands, including specialty-specific shortages, and payments should be linked to its ability to do just that.

However, reforming graduate medical education will likely have minimal effect on alleviating the physician shortage. Research suggests that other interventions, such as utilizing nurse practitioners and other nonphysician providers, may be more effective. The number of nonphysician providers has been growing steadily, but the potential of nonphysician providers to deliver care is hindered by laws that limit their ability to diagnose and treat patients on their own.

Reforming graduate medical education may be needed to prepare for future workforce demands, but allowing nurse practitioners to work independently—along with standardizing scope of practice laws nationwide—could expand access to care in the midst of a physician shortage.


Pivot tables, a feature of Microsoft Excel, are a powerful analytic tool that allow practices to organize data in a spreadsheet with ease, writes Lucien W. Roberts, III, MHA, FACMPE, administrator of Gastrointestinal Specialists, Inc., a 25-provider practice in Central Virginia. Rather than relying on the confusing and canned reports provided by the practice management system and EHR, Roberts says managers can use pivot tables to quickly sort data and produce actionable and meaningful reports. Roberts offers five ways he has used pivot tables to benefit his practice.

One method that increased revenues was creating a pivot table examining the return on investment for each physician's hospital work. This demonstrated significant differences in utilization and resulted in changes to the hospital coverage. Roberts also has a pivot table linked to the practice management system server that is updated daily, permitting the practice to study referral trends and quickly respond to concerns of referring physicians. This has contributed to increased referrals, he said.

Regarding Evaluation and Management (E/M) coding, Roberts uses a pivot table to evaluate coding patterns. This has identified probable undercoding and overcoding and has enabled the practice to address both through additional education. Roberts says his practice even identified a new office location by creating a pivot table that enabled them to analyze patient origin data by zip code, referring physician, payer mix and more. Finally, he has used pivot tables to improve reimbursement. While analyzing fee schedules using canned reports is tedious, a pivot table allows one to organize information by code by payer to look at variances, identify underpayments and negotiate better terms.


Although addiction is widespread in the United States, comprehensive addiction training is rare in medical education. A report by the National Center on Addiction and Substance Abuse at Columbia University blasted "the failure of the medical profession at every level—in medical school, residency training, continuing education and in practice" to sufficiently address addiction.

Now, years of pressure from doctors, medical students and patients to legitimize addiction medicine is resulting in small changes across the country. A few students have begun to specialize in the new field, which concentrates on prevention and treatment of addictions and the effect of addictive substances on other medical conditions. In June, the House of Representatives authorized a bill to reimburse education costs for providers who work in areas struggling with addiction.

Still, there are a mere 52 addiction medicine fellowships. In August, the first dozen finally received gold-standard board certification status from the Accreditation Council for Graduate Medical Education. While most medical schools now offer some education about opioids, programs rarely go deeper. But Boston University's school of medicine weaves addiction training into all four years. In a 75-minute session about the nuances of assessing a pain patient, students are being taught that language matters, to speak without blame and how to engage the patient with a joint decision-making, team approach.

Health Policy and Reimbursement

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The U.S. Food and Drug Administration (FDA) has announced a series of "critical and historic" enforcement actions associated with the sale and marketing of e-cigarettes to children. The agency has issued more than 1,300 warning letters and fines to retailers that illegally sold JUUL and other e-cigarette devices to minors during a nationwide, undercover operation targeting brick-and-mortar and online stores over the summer.

"We're committed to the comprehensive approach to address addiction to nicotine that we announced last year," said FDA Commissioner Scott Gottlieb. "But at the same time, we see clear signs that youth use of electronic cigarettes has reached an epidemic proportion, and we must adjust certain aspects of our comprehensive strategy to stem this clear and present danger. This starts with the actions we're taking today to crack down on retail sales of e-cigarettes to minors." Gottlieb said the agency will "also revisit our compliance policy that extended the dates for manufacturers of certain flavored e-cigarettes to submit applications for premarket authorization." He said FDA has asked five e-cigarette manufacturers to develop plans within 60 days to immediately mitigate youth sales, or face a potential decision by the regulator to reconsider extending the compliance dates for submission of premarket applications.


House Republicans have stripped a drug pricing amendment backed by President Trump from a healthcare spending bill. The provision, which passed the Senate with bipartisan support in August, would require drug prices to be disclosed in television advertisements for drugs in an effort to increase transparency and bring down prices. The proposal is part of Trump's plan to reduce drug prices.

Lawmakers and aides said that House Republicans objected to including the provision in the final version of the funding bill. Sen. Dick Durbin (D-Ill.), one of the sponsors of the provision, blamed pharmaceutical companies for using their influence to block the measure. After failing to include the provision in the underlying funding bill, Durbin offered it as an amendment before withdrawing it after other lawmakers said they did not want to risk passage of the larger health funding bill by voting on the amendment.


The comment period has now closed for the U.S. Centers for Medicare and Medicaid Services' (CMS) request for information regarding the Stark Law. The agency's potential changes to the physician self-referral law could have sweeping effects on the healthcare industry. The purpose of the request is "to transform the healthcare system into one that pays for value," according to the U.S. Department of Health and Human Services (HHS). "Removing unnecessary government obstacles to care coordination is a key priority for HHS," it added.

The American Podiatric Medical Association submitted comments to CMS with two requests. First, it proposed modernizing and simplifying regulatory burdens to facilitate doctors' participation in new practice models that come with complex financial arrangements. Second, it called for giving patients direct access to data sources on price transparency and quality of services so they can better see the value of care being recommended by the physician, regardless of financial stakes.

The American Hospital Association (AHA) also backs changes to the Stark Law. In previous testimony to a subcommittee of the U.S. House of Representatives, it said, "Congress should create a clear and comprehensive safe harbor under the anti-kickback law for arrangements designed to foster collaboration in the delivery of healthcare and incentivize and reward efficiencies and improvement in care. In addition, the Stark Law should be reformed to focus exclusively on ownership arrangements."


In a bid to reduce the burden on clinicians, medical organizations are urging Congress to consider modifications to a law requiring clinical decision support (CDS) use involving diagnostic imaging orders. The Protecting Access to Medicare Act (PAMA), which will not be implemented until 2020, will require referring providers to consult appropriate use criteria (AUC) prior to ordering advanced diagnostic imaging services for Medicare patients. If the ordering provider does not consult AUC rules through clinical decision support before the order is placed, the U.S. Centers for Medicare and Medicaid Services will not pay the for the imaging.

In a recent letter, physician organizations representing primary, specialty and surgical care asked lawmakers to modify PAMA so that healthcare professionals who meet the requirements of the Medicare Quality Payment Program (QPP) will be deemed compliant with the AUC Program. The groups argue that AUC consultation is inherent within the Quality Payment Program's dual tracks: the Merit-Based Incentive Payment System and alternative payment models, both of which hold clinicians accountable for quality and patient outcomes and for resource use.

The medical organizations argue that requiring clinicians to participate in a stand-alone AUC reporting program, in addition to the cost reduction and value-based activities of the QPP, will be "burdensome, duplicative and costly, and due to a lack of appropriate measures, will not aid in determining whether patients are better served by the program's implementation."

Medicine, Drugs and Devices

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An examination of medical records from 2006 to 2015 found that doctors provided no explanation for writing an opioid prescription 29 percent of the time, according to a study published in the Annals of Internal Medicine. The findings support widespread criticism that inappropriate prescribing practices have contributed to the opioid epidemic.

Researchers at Harvard Medical School and the Rand Corp. studied tens of thousands of medical records, focusing on more than 31,000 physician surveys that included a prescription for an opioid. They found that two thirds of opioid prescriptions included a pain diagnosis, usually for back pain, arthritis, diabetes or another chronic condition. Five percent were for pain related to cancer. "No pain diagnosis was recorded at the remaining 28.5 percent," the researchers wrote. Many patients had multiple ailments, so the researchers discarded any surveys that may have simply lacked space to record all the diagnoses. Still, many patients received renewals of opioids for apparently no good reason.

Doctors must write down why they are giving someone an opioid, the researchers said. "Whatever the reasons, lack of robust documentation undermines our efforts to understand physician prescribing patterns and curtails our ability to stem overprescribing," said Dr. Tisamarie Sherry, who worked on the study.

Meanwhile, a separate study published in JAMA Pediatrics found that only 24 percent of youths with an opioid use disorder had a prescription for buprenorphine, naltrexone or methadone, which can help people fight their addiction. The Boston Medical Center researchers noted that many doctors lack knowledge about the drugs and there is a stigma around their use.


The U.S. Food and Drug Administration (FDA) wants companies to do more to curb hacking and other security threats in devices, according to an audit report published by the U.S. Department of Health and Human Services' (HHS) inspector general office. The inspectors urged FDA reviewers to add cybersecurity to their "refuse to accept" checklist, which is a list of items that companies must submit at the beginning of the process to be considered for potential clearance or approval. The federal inspectors also recommended that FDA include cybersecurity discussions in their meetings with companies that seek to submit devices for approval and add it to the digital templates used for reviewing lower-risk devices.

FDA officials say they are working to update the agency's rules for how network-capable devices should be designed at their earliest stages with cybersecurity in mind. For instance, FDA could require device makers to create and distribute a "software bill of materials" that would identify all of the software that comes standard on a device. The agency is also considering forming a public-private CyberMed Safety Analysis Board that would serve as a "go-team" to investigate potential and actual device compromises at FDA's request. HHS's inspector general's office is currently preparing another report that will examine FDA's cybersecurity effort after devices have been allowed into the U.S. market.


According to Quest Diagnostics, 52 percent of Americans it tested in 2016 and 2017 misused prescription drugs, a figure that has remained relatively unchanged since 2013. Most of the misuse stemmed from positive results for nonprescribed or illegal drugs in addition to their prescriptions, Quest found.

Rates of nonprescribed opioid and amphetamine drug use as well as illicit drug use fell from 2016 to 2017, suggesting that efforts to reduce opioid use have been successful. However, the rate of nonprescribed and illicit drugs jumped among patients tested in treatment centers for substance abuse. Nonprescribed fentanyl and heroin use increased nearly 400 percent from 2016 to 2017, although the rates are likely much higher if accounting for synthetic fentanyl. Upticks in fentanyl use among treatment center patients were especially dramatic in individuals aged 18 to 44, increasing from 3.4 percent in 2016 to more than 29 percent in 2017, while positive heroin tests rose from 0.8 percent to 9.9 percent.

The healthcare industry must develop and support opioid alternatives for chronic pain management, said Dr. Jeffrey Gudin, a co-author of the analysis. In the meantime, the industry overall should better monitor patients taking prescription opioids and optimize prescription drug monitoring programs to track patient behavior, he said. "This is a reminder that sharp restrictions on opioid prescribing alone will not solve the prescription drug epidemic," Gudin said.