News From ACFAS

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Hotel poachers are real—they falsely represent themselves as our official housing partner and take your money but don’t give you a room in which to stay. Watch out for these pirates as you prepare to book your hotel room for ACFAS 2019 in New Orleans. Remember, the safest and most secure way to reserve your hotel room at the lowest rate is through acfas.org/neworleans.

The College’s official housing partner is onPeak. If any organization other than onPeak contacts you, do not give your credit card information or a cash deposit. Join us On the Road this fall for a full harvest of surgical strategies and solutions you can turn to when working “In the Trenches” with your colleagues.

Day 1 of this two-day seminar and workshop starts with the presentation, “Controversies and Complications,” followed by an informal panel discussion and the opportunity to share your own work cases.

Interactive lectures plus two hands-on sawbones labs focused on fixation options, osteotomies and other procedures round out Day 2. Faculty will then close the seminar with “Tips, Tricks and Quips” you can put to use as soon as you return to the office.

The On the Road nationwide tour kicks off this weekend and continues through the spring. Visit acfas.org/ontheroad to register now. Volunteer to serve on a 2019 ACFAS committee, Clinical Consensus Statement panel or as a reviewer of Scientific Literature. ACFAS is looking for members who are leaders, thinkers, team players and hard workers to work with the College to shape the future of our profession.

To apply to volunteer, visit acfas.org/volunteer. The application deadline is October 31, 2018. Attention Associate and Fellow members— due to popular demand, dues invoices are again arriving earlier to give you more time to pay before the end of the calendar year. Watch your email for renewal instructions for the 2019 calendar year. The deadline for payment will remain the same: December 31, 2018. You can pay your dues online now or via mail or fax once you receive your reminder.

To learn more about the many benefits your ACFAS membership provides, visit the Member Center on acfas.org. If you missed your chance to watch the College’s two free webinars from last month, don’t worry—archived recordings are now available on acfas.org. The webinars give good tips on managing student loan debt and provide firsthand advice from two residency directors on navigating the process to land the residency of your choice. Each presentation runs about an hour in length.

Foot and Ankle Surgery

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Chronic ankle instability (CAI) is the main complication of ankle sprains and requires surgery if nonoperative treatment fails. Surgical ankle stabilization techniques can be largely classified into two groups: repair involving retensioning and suturing of the anterior talofibular ligament (ATFL) and calcaneofibular ligament (CFL) and reconstruction using a tendon graft. The objective of this prospective multicenter study was to assess the feasibility, morbidity and short-term outcomes of arthroscopic ankle-stabilization techniques.

Consecutive patients scheduled for arthroscopic treatment of CAI were included prospectively. Of the 286 included patients, 115 underwent ligament repair and 171 ligament reconstruction. Mean follow-up was 9.6 months. The overall patient satisfaction score was 8.5/10. The AOFAS and Karlsson scores improved significantly between the pre- and postoperative assessments, from 62.1 to 89.2 and from 55 to 87.1, respectively. These scores were not significantly different between the groups treated by repair and by reconstruction. Neurological complications occurred in 10 percent of patients and consisted chiefly in transient dysesthesia, with neuroma in 3.5 percent of patients. Cutaneous or infectious complications requiring surgical revision developed in 4.2 percent of patients.

Arthroscopic treatment is becoming a method of choice for patients with CAI, as it allows a comprehensive assessment of the ligament lesions, the detection and treatment of associated lesions and repair or reconstruction of the damaged ligaments. These simple and reliable arthroscopic techniques seem as effective as conventional surgical techniques. The rate of cutaneous complications is at least halved compared to open surgery. The researchers concluded that arthroscopic ankle stabilization repair and reconstruction techniques hold considerable promise but require further evaluation to better determine the indications of repair versus reconstruction and to obtain information on long-term outcomes.


Low tibial osteotomy is an effective joint-preserving surgery for ankle arthritis. However, poor postoperative wound healing, infection and delayed or nonunion of bones remain significant concerns. In this study, researchers describe a modified distal tibial oblique osteotomy procedure and report preliminary results for varus ankle arthritis.

The osteotomy path consisted of an oblique doglegged line from the lateral end of the distal tibia to a proximal point about one third from the lateral edge and continuing along an arc defined by virtual coronal-plane rotation of the doglegged line to the medial edge. After osteotomy, the distal tibial fragment was rotated distally in the coronal plane for realignment while maintaining contact with the proximal tibia and the distal tibial fragment. The resulting wedge-shaped gap was filled with artificial bone blocks and tibial bone projecting medially from rotation. A locking plate was then applied for stabilization. Researchers evaluated seven ankles from six osteoarthritis patients both clinically and radiographically following this procedure.

Bone union was achieved within three months for all patients. The Japanese Society for Surgery of the Foot ankle-hindfoot scale improved from a mean of 38.4 points preoperatively to 85.7 points at the latest follow-up. No wound healing problems, infections or nerve disturbances were observed. Multiple radiographic parameters were also improved following the operation.

This procedure maintains close bone contact for better postoperative union, obviates the need for iliac bone harvesting and reduces tension on medial soft tissue. The researchers believe these modifications are potential advantages for achieving stable results in patients with ankle osteoarthritis.


Residual symptoms often persist even after successful operative reduction and internal fixation (ORIF) of ankle fractures. Concurrent ankle arthroscopic procedures (CAAPs) have been proposed to improve clinical outcomes; however, insufficient evidence exists supporting this practice. The purpose of this study was to investigate the reoperation and complication rates after ORIF of ankle fractures with and without CAAPs.

Reoperations and complications after ORIF of ankle fractures were identified using the PearlDiver database from January 2007 to December 2011. The CAAPs included bone marrow stimulation, debridement, synovectomy and unspecified cartilage procedures. Reoperation procedures consisted of ankle fracture repeat fixation, arthroscopic procedures, osteochondral autograft transfers and ankle arthrodesis.

Of the 32,307 patients who underwent ankle fracture fixation, 248 received CAAP and 32,059 did not. No significant difference was found in the reoperation rate between the two groups. Of the 248 patients in the CAAP group, 19 underwent reoperation, of which 13 were arthroscopic debridement and six were either ankle refixation or osteochondral autograft transfer. For the non-CAAP group, 3,021 reoperation procedures were performed, consisting of ankle refixation in 83.2 percent, arthroscopic procedures in 14.3 percent and ankle arthrodesis in 2.5 percent. The complication rate in the non-CAAP group included wound dehiscence in 2.4 percent, wound surgery in 0.4 percent, deep vein thrombosis in 0.8 percent and pulmonary embolism in 0.4 percent. No complications were detected in the CAAP group.

The researchers concluded that ankle fracture fixation with CAAPs did not increase the postoperative reoperation rate compared with ankle fracture fixation without CAAPs.

Practice Management

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A new Stanford University School of Medicine white paper details recommendations by healthcare industry experts for medical practices to improve the effectiveness of their electronic health records (EHRs). By implementing these suggestions, industry experts anticipate EHR systems will have an overall positive effect on the healthcare industry by 2028.

First, experts recommended that medical practices invest in adequate EHR training when onboarding physicians. "The amount of training physicians get in their EHRs has a big impact on their own levels of satisfaction," the authors wrote. Experts also suggested that medical practices enlist physicians to help prioritize EHR development tasks and assist in clinical workflow design. Furthermore, experts advised medical practices to prioritize delivering EHR development projects soon after physicians request them. They emphasized the value of establishing an EHR governance process that gives organizations the ability to effectively respond to health emergencies and crisis scenarios.

Presenting analytics data to physicians in a user-friendly format at the point of care can further optimize EHR use. Additionally, offloading nonessential EHR data entry tasks to ancillary staff members can help reduce clinician burden and increase provider satisfaction. Another suggestion is to allow patients to digitally maintain their EHRs by providing family history, medical history, medications and health monitoring data, among other information. Finally, experts suggested that medical practices ditch their fax machines and "embrace electronic communications," as well as begin accepting electronic payments.


Terminating a provider's employment with a physician practice can be a sensitive process and should be handled carefully. For example, when terminating someone without cause, practices should check the written employment or related agreement with the provider to be certain how much notice is required. They should also confirm how notice is required to be made under the agreement, whether that entails emailing a provider or informing them in person.

When terminating someone with cause, make sure the reason the practice is terminating the provider is actually in the provider's agreement or is otherwise a clear violation of it. Carefully document the reasons that led to termination and any cure opportunity provided. The practice should also consider whether it might be easier to use a "without cause" termination approach even if the practice believes cause exists. The expense can often be less than the legal fees associated with a disputed "for cause" termination.

In addition, it is advisable to consult with counsel in certain situations. For example, has the provider made an accusation of mistreatment or harassment? If so, has the practice investigated and followed through? The final step is entering into a separation agreement. This can release both parties from liability, among other benefits. The language should be reviewed by legal counsel to be certain all relevant laws that apply to the provider under state and federal laws are properly addressed. This kind of release also typically requires some consideration or can include additional compensation from the practice to the provider.


High-quality scribes can help significantly reduce physician electronic health record (EHR) documentation burden, according to a recent study published in JAMA Internal Medicine. Researchers enlisted scribes from a private agency to work with 18 primary care physicians (PCPs) from July 2016 to June 2017. They found that scribes were associated with less after-hour EHR documentation by PCPs and were associated with PCPs completing encounter documentation by the end of the next business day. Scribes also increased the likelihood that PCPs would spend more than 75 percent of a visit interacting with the patient. In addition, more than 60 percent of patients said scribes made a positive impact on visits, while 88 percent of PCPs reported satisfaction with the quality of scribe EHR documentation.

The research shows that scribes can have a significant impact on a key factor for physician burnout, the authors wrote. "Emerging evidence indicates that EHRs, as currently implemented, increase clerical workload and physician stress and interfere with direct physician-patient interaction, thereby diminishing professional satisfaction and contributing to professional burnout," the researchers said. The scribes also demonstrated a likelihood of improving work-life balance, which has been connected to physician burnout.

The authors noted that some potential pitfalls associated with employing scribes in the primary care setting include the cost of scribe services and scribe quality, which was high with the private service used in the study but varies with internal scribes.

Health Policy and Reimbursement

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The final version of the massive opioid package released by Congress would give the U.S. Food and Drug Administration (FDA) new powers to crack down on drug imports, but it also includes a provision to protect people seeking to buy cheaper prescription medication from other countries. The bill requires that the agency take steps to accelerate development of nonopioid painkillers and to limit the supplies of the drugs. Among those steps, the bill expands FDA's power to "debar" individuals "from importing or offering for import into the United States a drug" if they are violating certain regulations, including importing "mislabeled" medications, which includes any from overseas.

The original House version of the bill included a provision that defined those importers to exclude regular people who were importing personal prescriptions from foreign countries. That definition had been cut without explanation from the Senate's version of the bill. Congressional staffers said lawmakers believed it was unnecessary since FDA already has discretion to overlook personal imports and told lawmakers it has no plans to change the policy. Nevertheless, advocates for importation of cheaper drugs pushed back, warning that policies are not permanent and could be changed at any time.

The definition appears to have been added back to avoid any controversy that might have interfered with smooth passage of the opioid legislation. Advocates see the measure as a major step in recognizing the legitimacy of importing medications from Canada and other countries where they are less expensive.


The U.S. Department of Health and Human Services (HHS) has awarded more than $1 billion in opioid-specific grants. The awards support the agency's Five-Point Opioid Strategy, which was launched last year and recently enhanced. "HHS updated its strategic framework for tackling the opioid crisis, which uses science as a foundation for our comprehensive strategy," said Admiral Brett Giroir, Assistant Secretary for Health and Senior Advisor for Opioid Policy. "With these new funds, states, tribes and communities across America will be able to advance our strategy and continue making progress against this crisis."

The Substance Abuse and Mental Health Services Administration (SAMHSA) within HHS awarded more than $930 million in State Opioid Response grants to support a comprehensive response to the opioid epidemic and expand access to treatment and recovery support services. The grants aim to address the opioid crisis by increasing access to medication-assisted treatment using the three medications approved by the U.S. Food and Drug Administration for the treatment of opioid use disorder, reducing unmet treatment need and reducing opioid overdose-related deaths through the provision of prevention, treatment and recovery activities for opioid use disorder.

States received funding based on a formula, with a 15 percent set-aside for the 10 states with the highest mortality rate related to drug overdose deaths. Other funding provided through this program, including $50 million for tribal communities, will be awarded separately. In addition, SAMHSA awarded about $90 million to other programming for states and communities to expand access to medication-assisted treatment, to increase distribution and use of overdose reversal drugs and to expand workforce development activities.

Medicine, Drugs and Devices

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The U.S. House of Representatives has cleared two bills that would bar pharmacy benefit managers (PBMs) from putting gag clauses into contracts with pharmacies. Gag clauses prevent pharmacists from informing customers that they could save money if they paid the full price for a prescription out of pocket rather than using their insurance and paying the copay amount. Both bills passed the Senate unanimously and are expected to be signed into law by President Trump.

A study published in the Journal of the American Medical Association found that 23 percent of prescriptions filled through insurance ended up costing more for customers than if they had paid out-of-pocket. In addition, a 2016 industry survey found that one out of five pharmacists were limited by gag clauses more than 50 times per month.

Gag clauses cost the U.S. Centers for Medicare and Medicaid Services (CMS) money as well. In September, CMS Administrator Seema Verma sent a letter to all Medicare Part D plan sponsors saying the agency requires them to ensure enrollees pay the lesser of the Part D negotiated price or copay, or else face CMS compliance actions. Part D plan sponsors must also tell their network pharmacies to disclose the price of the lowest cost generic version of the drug.


Simply by monitoring network traffic, hackers are using error messages from connected medical devices to gain valuable insights into the network and inner workings of a device's application, new research shows. These insights are then used to refine the attacks, increasing the chance of a successful hack. Zingbox, a provider of a healthcare Internet of Things (IoT) analytics platform, released the findings as part of a study on new trends in connected medical device hacking that could affect patients' protected health information.

The researchers discovered that information shared as part of common error messages can be used by hackers to compromise connected devices. In addition, hackers can manipulate medical devices into sharing detailed information about the device's inner workings. Leveraging this information accelerates a hacker's access to a hospital's network, the researchers found. "Hackers are finding new and creative ways to target connected medical devices. We have to be in front of these trends and vulnerabilities before they can cause real harm," said Xu Zou, Zingbox CEO and cofounder.

The research also revealed that the healthcare industry has made significant progress in collaborating across providers, vendors and manufacturers to generate patches for medical devices. However, the researchers say, additional work and increased collaboration between security vendors and device manufacturers are needed.


To fix opioid overprescribing without leaving pain patients behind, some experts are calling for shifts in how doctors prescribe these drugs rather than sweeping legal changes. For example, in a study published in Science in August, researchers found that notifying doctors via letter that one of their patients had died from an overdose helped reduce opioid prescriptions. Experts suggest that nudges like the one in the Science study are a better solution than the more heavy-handed policy efforts, such as strict legal limits on doctors' opioid prescribing abilities, that lawmakers are enacting across the country.

Experts recommend reducing opioid prescriptions with caution so patients who may genuinely need opioids are not abandoned. They also propose ideas that focus on nudging, rather than mandating, prescribers to do the right thing. For example, a recent study in JAMA found that simply lowering the default number for opioids prescribed in an electronic medical record system slashed the number of pills prescribed. In addition, experts say it is important not to abruptly cut off patients who are on opioids, warning that could lead to unnecessary pain or withdrawal or even push patients toward dangerous illicit drugs.

Furthermore, experts recommend treating pain with evidence-based, nonopioid interventions for pain. They say the problem with many efforts to limit opioid prescriptions is that they do not make alternative pain treatments more accessible. Another key issue is that doctors receive little training on pain, which may require serious systemic reform in the healthcare system. Finally, experts recommend looking at pain more comprehensively and addressing the "root" cause of the pain—which could be seemingly invisible psychological or other issues.