News From ACFAS

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Book your hotel accommodations safely and securely for ACFAS 2019 in New Orleans by using onPeak, our official housing partner. Receive the lowest guaranteed rate for your room and also protect yourself from “hotel poachers,” such as Conventioneers and Global Expo Travel, who will gladly take your money but then leave you roomless.

Choose from any of these exclusive hotels:

• Hampton Inn & Suites Downtown/French Quarter
• Hilton New Orleans Riverside
• JW Marriott New Orleans
• Le Meridien New Orleans
• New Orleans Marriott
• Renaissance Pere Marquette
• Westin New Orleans Canal Place

Visit acfas.org/neworleanshousing to reserve your room now, and we’ll see you in New Orleans! Residents, get a head start on your ACFAS 2019 experience. Plan to attend the College's first-ever Residents' Day on Wednesday, February 13, 2019 at the Ernest N. Morial Convention Center in New Orleans and hear seasoned foot and ankle surgeons share their tips on:

• Transition to Real World
  How to Prepare for an Interview
  Contracts: Accepted "Standards" for Contracts in Different Practice Settings
• From the Patient Chair to the OR/Complications
  My First Worst Case: 20/20 Hindsight First Days in Practice
• Your First Five Years
  Changing Course: Looking for Your Second Job
• And more!

The day includes lunch and will end with an informal beer and wine networking event featuring open Q&A. Agenda and registration details will be available soon on acfas.org/neworleans—stay tuned! Give your patients the tools they need to recognize the signs and symptoms of capsulitis before it progresses to crossover toe. Head to the ACFAS Marketing Toolbox to download our latest free PowerPoint presentation, Capsulitis & Crossover Toe: Like Walking on a Pebble, and:

• Use it when speaking with patients in your office or at community health events this fall
• Project it as a slideshow in your waiting and exam rooms
• Prerecord it and post it to your practice website and social media channels

The presentation defines capsulitis and its causes and outlines symptoms during the early and late stages of the condition. Surgical and nonsurgical treatment approaches are also included.

Be sure to customize Slide 15 in the file with your practice's contact information and use the accompanying script to guide your talks.

Visit acfas.org/marketing to access the complete library of PowerPoint presentations and to download other free resources, such as healthcare provider referral tools, infographics and the FootNotes patient newsletter, that can help strengthen your end-of-year practice marketing efforts. The easiest way to stay in touch with the College is by making sure your ACFAS member profile is current. Log into your account at acfas.org to:

• Update your work and personal email addresses, fax number and your work, home or cell numbers.
• Confirm your preferred mailing address for The Journal of Foot & Ankle Surgery and ACFAS Update.
• Allow your colleagues to contact you through the College’s online membership directory.
• Include yourself in the “Find an ACFAS Physician” search tool on FootHealthFacts.org.

Let us know of any changes to your contact information throughout the year so you can stay connected with your colleagues and the College!

Foot and Ankle Surgery

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Following failure of conservative treatment, a dorsal cheilectomy can be performed for patients in early stages of hallux rigidus by a traditional open approach or by a minimally invasive technique. Researchers reported their clinical outcomes following minimally invasive dorsal cheilectomy (MIDC). This study examined 89 patients (98 feet) with symptomatic hallux rigidus treated between 2011 and 2016. Manchester-Oxford Foot Questionnaire (MOxFQ) scores and visual analog scale (VAS) pain scores were collected. The mean follow-up was 50 months.

The average VAS score improved from 8 preoperatively to 3 postoperatively. The mean MOxFQ summary index score decreased from 58.6 preoperatively to 30.5 postoperatively. All three MOxFQ domains also improved. Swelling took an average of 5.3 weeks to settle. Results included two wound infections and two delayed wound healings. Two patients had transient nerve paraesthesia, while two patients had permanent numbness in the dorsomedial cutaneous nerve distribution. Twelve patients underwent reoperation, of which seven had a first metatarsophalangeal joint arthrodesis for ongoing pain, four had repeat cheilectomy for residual impingement and one had an open removal of loose bone.

The results indicate that MIDC resulted in improvement in patient-reported outcome measures and was a safe technique with minimal complications. The complications were similar to open cheilectomy. There was an associated learning curve as five of the reoperations were due to incomplete cheilectomy. Coughlin grade 1 did well with MIDC as with open cheilectomy since none led to an arthrodesis. However, 10 percent of the grade 2 and 3 cases led to an arthrodesis.


Current literature is unclear about which joint is most "at risk" to yield a nonunion in the performance of triple arthrodesis of the foot. Disagreement also exists about the best methods of joint preparation. A retrospective radiographic review was conducted of all primary triple arthrodeses performed within a large Northern California health maintenance organization between January 2007 and June 2013. Data documenting joint preparation techniques was collected and postoperative imaging was reviewed to measure time to osseous union. Patient demographics were also collected.

A total of 152 patients (157 procedures) met the inclusion criteria. The overall nonunion rate for triple arthrodesis in this series was 29.9 percent. The nonunion rate of the talonavicular joint was 20.4 percent, the nonunion rate of the calcaneocuboid joint was 17.2 percent and the nonunion rate of the subtalar joint was 8.9 percent. The researchers concluded that the most likely joint to obtain nonunion during triple arthrodesis was the talonavicular joint. Furthermore, the most effective joint preparation technique was a combination joint resection or curettage with fish scaling.


The purpose of this study was to evaluate and compare complication rates and postoperative outcomes in patients with ankle debridement alone versus debridement and hinged ankle distraction arthroplasty.

A total of 50 patients with posttraumatic ankle osteoarthritis (OA) with a mean age of 40.0 ± 8.5 years were included in this prospective randomized study: 25 patients in the ankle debridement alone group and 25 patients in the debridement and hinged ankle distraction group. The mean follow-up was 46 ± 12 months. The clinical and radiographic outcomes were evaluated at the six-month and three-year follow-up using the visual analog scale (VAS), American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot score, SF-36 quality of life score and van Dijk OA classification. A Kaplan-Meier survival analysis was performed to calculate the survival rates at three years and at five years.

Both patient groups experienced significant pain relief, functional improvement and improvement in quality of life postoperatively. In total, 26 major secondary procedures were performed. The overall survival rates in the debridement and ankle distraction group were 74 percent and 59 percent at three years and five years, respectively. The overall survival rates in the ankle debridement alone group were 49 percent and 34 percent at three years and five years, respectively.

The study demonstrated comparable postoperative functional outcome and quality of life. However, rate of postoperative revision surgery was significantly higher in the ankle debridement alone group.

Practice Management

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Before becoming president of his independent 85-physician practice in Wichita, Kansas, anesthesiologist David Norris went back to school for his MBA. He has since focused on the top areas physicians struggle with: finances and accounting. Norris says talking about finances is even more important than it was five or 10 years ago because margins are decreasing as costs to run a practice rise. "I think financial intelligence will help you run your practice better," he says. If practices lack financial know-how, they will eventually need to shut their doors, he adds. "I think it behooves you as a physician owner to really sit down, spend some time and try to get some understanding on how to be profitable. Then I think you can actually have a long, thriving practice," Norris says.

In addition, physicians can improve patient care if they can find a more efficient, effective process and demonstrate that it will save money or reduce errors. Financial intelligence can also help physicians in private practices by improving their ability to "participate in contract negotiations, whether that's fee for service or managed care," Norris says. "When they start bundling those payments, you want to have a very clear understanding of what your costs are, so you have a much better idea of where you need to be to participate."

For physicians who want to gather financial intelligence but are intimidated by the topic, Norris says, "The first step is realizing, 'I don't have the knowledge.' The second step is trying to locate resources that will help you rapidly master that material," whether that is online courses, books or resources offered by a local medical society.


A new study from the U.S. Centers for Disease Control and Prevention (CDC) published in the Morbidity and Mortality Weekly Report estimated that flu vaccination rates among healthcare professionals (HCPs) have stagnated at about 74 percent since 2014. The rate was particularly low among those working in long-term care settings and settings where vaccination was not required, promoted or offered on-site. Vaccination rates were highest in workplaces where they were required, and they can be improved by offering worksite vaccination at low or no cost for one day or by actively promoting vaccination.

"Influenza vaccination coverage among healthcare personnel working in long-term care settings ... continues to be consistently lower than that among healthcare personnel working in all other healthcare settings," the authors write. "Influenza vaccination among healthcare personnel in long-term care settings is especially important because influenza vaccine efficacy is generally lowest among the elderly, who are at increased risk for severe disease." The researchers suggest deploying workplace vaccination programs that have been successful in increasing coverage in hospital settings, such as vaccination requirements. They also believe that use of CDC's digital campaign and long-term care employers' toolkits could boost influenza vaccine coverage among HCPs.


Voice-enabled, AI-powered virtual assistants have the potential to reduce physician burnout and enhance the patient experience by diminishing the difficulty of locating information in the electronic health record (EHR), among other benefits. For example, this technology could summarize a patient's recent history via smartphone before each encounter, respond to the doctor's queries about information stored in the EHR during the visit and help order medication, labs and diagnostic tests. This means the doctor's eyes could stay focused on the patient instead of on the computer screen and that the doctor's day would be less filled with administrative tasks.

Some of these technological advances are already available through a commercial venture between Nuance Healthcare, a division of Nuance Communications Inc., and Epic Systems Corporation. "These virtual agent capabilities not only allow [doctors] to complete the work faster, but a highly productive physician can save upwards of two hours a day using this technology," says Peter Durlach, senior vice president, strategy and new business development for Nuance. It also contributes to better documentation to meet regulatory requirements, he says. In September, Nuance and Epic released the first version of a conversational virtual assistant for the healthcare market through Epic Haiku, a mobile app for physicians.

Health Policy and Reimbursement

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U.S. companies are increasingly opening clinics on or near their worksites or bringing in temporary setups to ensure that their employees get annual physicals. The National Business Group on Health predicts 56 percent of large employers will have an on-site or nearby health center by 2019, up from 47 percent in 2016. In many cases, employers are offering free primary care or charging only a small fee, noting that they can improve employee health and reduce even larger bills in the future that stem from unmanaged chronic conditions or unnecessary emergency room visits.

Providing convenient care can also help entice new workers and cut down on time away from the job, but this transition means workers will need to change how they use the healthcare system. Furthermore, companies, which do not see individual medical records, must wait for some potential benefits from their investment, such as a drop in healthcare costs, to materialize. Most of the businesses surveyed by the National Business Group on Health have 10,000 or more employees, but benefits experts also see this trend expanding in smaller businesses, with some companies partnering to pay for a nearby clinic that they share.


The U.S. Centers for Medicare and Medicaid Services (CMS) has announced a 6 percent decrease in Medicare Advantage (MA) premiums in 2019 due to MA enrollment, health plan options and benefits hikes. CMS said the average 2019 MA premium will fall from $29.81 to $28, adding that this will improve health plan affordability for most beneficiaries. Eighty-three percent of enrollees are expected to have either the same or a lower premium next year, while CMS estimated that 46 percent of MA beneficiaries in their current plan will have a $0 premium.

MA is also offering 600 more health plan options and boosting the average number of MA choices for consumers. An estimated 3,700 MA health plans will be available in the market in 2019, with 91 percent of beneficiaries able to choose from 10 or more options. CMS expects MA enrollment to increase from 20.2 million to 22.6 million enrollees next year. "Medicare Part D and Medicare Advantage demonstrate the successes possible when we harness consumer choice and private-sector innovation to improve care and lower cost," said U.S. Department of Health and Human Services Secretary Alex Azar. "Meanwhile, the significant steps taken to maximize competition among Medicare Advantage plans and to support and empower Medicare beneficiaries are a crucial piece in allowing patients to define and drive value."


The Senate has passed a bipartisan opioids bill that sets up, expands and reauthorizes programs and policies across nearly all federal agencies. It now goes to President Trump to sign. The legislation will mandate that the U.S. Postal Service screen packages for fentanyl shipped from overseas, mainly China. Public-health proponents praise the bill's increased attention to opioid treatment and its creation of a grant program for comprehensive recovery centers that include housing, job training and mental and physical healthcare. The measure would also boost access to medication-assisted treatment that helps addicts safely wean themselves off opioids.

Furthermore, the bill lifts an obscure rule that has long banned Medicaid from covering beneficiaries with substance abuse disorders who were receiving treatment in a mental health center with more than 16 beds, by now permitting 30 days of residential treatment coverage. "This legislation edges us closer to treating addiction as the devastating disease it is, but it neglects to provide the long-term investment we've seen in responses to other major public health crises," said Lindsey Vuolo at the Center on Addiction. "We won't be able to make meaningful progress against the tide of addiction unless we make significant changes to incorporate addiction treatment into the existing healthcare system."

Medicine, Drugs and Devices

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U.S. Food and Drug Administration (FDA) Commissioner Scott Gottlieb, MD, recently detailed four steps the agency is taking to bolster its cybersecurity program for medical devices. The first step is a cybersecurity "playbook." Gottlieb said FDA has partnered with Mitre Corp., a nonprofit that operates federally funded research and development centers, to develop a playbook to help hospitals and health systems with cybersecurity readiness for medical devices. The playbook outlines how to develop medical device inventories, conduct staff training exercises and take steps to reduce patient safety concerns. In addition, the agency will establish information sharing analysis organizations (ISAOs) to gather and disseminate information about cybersecurity risks. One ISAO will bring together device makers to share information about potential vulnerabilities and emerging threats, while another will encourage government agencies to develop collaborative responses to cyberthreats.

Another way FDA is enhancing medical device security is through new premarket guidance. This month, the agency intends to release an update with new cybersecurity guidance, such as asking manufacturers to provide a "cybersecurity bill of materials," or a list of commercial and off-the-shelf software and hardware components in a device that could be susceptible to vulnerabilities. Finally, the new FDA Center of Excellence for Digital Health will support a cybersecurity unit focused on medical devices, including those that are software-based or fall under the umbrella of digital health.


Multifocal interventions that targeted patient and public demand, promoted prescriber awareness and accountability and set up tools for clinical leadership accountability helped reduce opioid overprescribing, according to a new study published in JAMA Network Open.

Researchers conducted a quality improvement study and compared the opioid prescriptions for six months before the intervention with prescriptions for 16 months after the intervention. The intervention domains included prescriber accountability and education, greater oversight by measurement of individual prescribers, tools to right-size postoperative discharge prescriptions, reductions of default amounts from usual opioid prescription orders and professionally written patient and public education about opioid risks and alternatives.

The researchers recorded more than 44,000 clinical encounters per month. They found that compared to baseline, and for each clinical encounter, morphine milligram equivalents declined 58 percent, opioid prescriptions fell 38 percent and morphine milligram equivalents for each opioid prescription had dropped 34 percent by study's end. "The magnitude of the achieved reduction stands out in comparison with other less successful efforts in which either policies alone or data sharing without follow-up were used," the researchers wrote.


Thermal imaging is more effective than traditional methods at predicting a diabetes-related foot ulcer's size and the healing trajectory, according to a study published in the Journal of Diabetes Science and Technology. The study, which was the first of its kind, used thermal imaging to quantify the size and predict the healing status of recently developed ulcers. Measuring an ulcer's area and temperature are effective in determining its treatment and duration, but existing methods can be inaccurate because many factors can interfere with the healing process.

The study used thermal imaging to assess diabetes-related foot ulcers in the first four weeks of ulceration. Researchers took thermal and color images of 26 neuropathic diabetes-related foot ulcers (11 healing/15 nonhealing) from people with type 1 and type 2 diabetes. To measure ulcer size, thermal images were segmented into areas with similar temperature. The size of the patch corresponding to the wound bed was considered the ulcer's physical size. This was more accurate than traditional methods. The research found the wound bed's isothermal area was lower at two weeks compared to baseline, which corresponded with a 50 percent reduction in area of diabetic foot ulcers at four weeks.

Principal researcher Dr. Behzad Aliahmad said the study demonstrated for the first time that isothermal maps of thermal images of the wound bed from week one to week two were suitable for predicting the healing trajectory. Based on their work, the researchers want to see thermal imaging used as an inexpensive and real-time option to identify wounds that may have delayed healing.