News From ACFAS

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Management of patients with acute gout can be challenging for any healthcare practitioner, but ACFAS and the American Association of Nurse Practitioners^® (AANP) have partnered to develop the Clinical Consensus Statement (CCS), Etiology, Diagnosis and Treatment Consensus for Gouty Arthritis of the Foot and Ankle, to aid in the diagnosis, treatment and prevention of this disease.

The joint CCS establishes consistent and collaborative care guidelines for all healthcare providers, including foot and ankle surgeons and NPs, to better understand patients at risk for developing the disease and to assist those who are undergoing treatment for gout. Among the CCS’s most significant findings are:

• Age, diet and alcohol consumption are risk factors for gout.
• Advanced imaging is not necessary to diagnose gout.
• Joint aspiration and microscopy are the gold standards for making the diagnosis of gout.
• Nonsteroidal anti-inflammatory drugs should be used as the first-line treatment for acute gout.
• Long-term medications, such as allopurinol, are necessary in the treatment of recurrent gout.
• Multidisciplinary referral provides optimal care in cases of recalcitrant gout.
• Patient education should include dietary modification, medication adherence and follow-up care with their assigned healthcare providers.

“All health professionals, including foot and ankle surgeons and NPs, can use this CCS as a guide to assess risk factors, timely diagnose and accurately formulate treatment plans for patients with gout,” says the CCS’s lead author Roya Mirmiran, DPM, FACFAS. “Keep this CCS close at hand as an ongoing reference so you always have the answers and can provide the best care for your patients.”

Read the CCS now at acfas.org/ccs or jfas.org. Today is the deadline to volunteer to serve as an ACFAS committee member, Clinical Consensus Statement panelist or Scientific Literature reviewer. Don’t miss your chance to help the College shape the future of our profession in 2019.

If you would like to volunteer, visit acfas.org/volunteer to apply.

The only creatures scarier than ghouls and goblins are hotel poachers—unauthorized web trolls who may promise you an inexpensive hotel room for ACFAS 2019 in New Orleans…but then leave you roomless and your wallet empty.

Guard against hotel poachers by booking your hotel room safely and securely with onPeak, our official housing partner. Receive the lowest rate and rest easy knowing that your room will be ready and waiting for you in New Orleans.

Register for ACFAS 2019 and reserve your hotel room today at acfas.org/neworleans. Which came first—the chronic ankle instability or the ankle sprain? Answer this question and others for your patients with our newest free PowerPoint presentation, Chronic Ankle Instability & Ankle Sprains: One Thing Can Lead to Another, available now in the ACFAS Marketing Toolbox.

Use the PowerPoint and accompanying script to help your patients understand the link between chronic ankle instability and ankle sprains and how each is treated. You can also display the PowerPoint as a slideshow in your waiting and exam rooms and post it to your practice website and social media pages.

Access the complete library of PowerPoint presentations at acfas.org/marketing as well as other free resources to promote your practice and educate your patients.

Foot and Ankle Surgery

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The "horseman" procedure is a surgical technique used to correct the talocalcaneal joint displacement of severe idiopathic flatfoot in children while maintaining the reduction with a temporary talocalcaneal screw. While this technique has been used since the early 1960s, little has been reported on its results. The objectives of this study were to estimate the correction, functional results and postoperative complications of the horseman procedure.

Researchers conducted a retrospective study on 23 consecutive patients (41 cases) who underwent the horseman procedure for a talocalcaneal joint displacement. Mean follow-up was 8.9 years, and eight patients (12 feet) had reached bone maturity at last follow-up. Mean age at surgery was 6.6 years. At last follow-up, all but two patients (8.7 percent) and four cases (9.8 percent) were asymptomatic. The talocalcaneal divergence on anteroposterior and lateral radiographic views was reduced by 8.9° and 11.4°, respectively, after the surgery, and the correction was maintained with loss of 0.7° and 2.9°, respectively, at final follow-up. The talonavicular coverage angle was reduced by 25° without loss of correction at last follow-up. The calcaneal pitch angle did not change after the surgery. Mean American Orthopaedic Foot and Ankle Society score increased from 88.7 of 100 preoperatively to 99 of 100 at last follow-up. No major complications occurred.

The authors concluded that the horseman procedure allows an immediate and lasting correction of severe idiopathic flatfoot in children.


Studies have shown a decline in the incidence of late consequences and the socioeconomic burden of intra-articular fractures of the calcaneum when treated by surgical fixation. Operative management of displaced intra-articular calcaneal fractures (DIACF) pose significant challenges, such as technical difficulty, wound healing and long-term pain and disability.

All patients presenting to the emergency room with DIACF over a period of two years and matching the inclusion criteria were enrolled in this study. Percutaneous fixation with a 4 mm CC screw was undertaken with a minimally invasive sinus tarsi approach. All patients were available for a minimum follow-up of 24 months. Six radiological parameters were assessed, and functional outcome was evaluated using the American Orthopaedic Foot and Ankle Society (AOFAS) score.

Thirty-four patients with 42 calcaneal fractures were included in the study. All radiological parameters were attained within anatomic normal range and maintained at 24 months of follow-up. AOFAS score showed a mean value of 90.10, which is considered an excellent outcome. Superficial wound infection was seen in two patients, but no patients required a revision surgery.

The researchers concluded that displaced intra-articular fractures pose a treatment dilemma, more so in cases of soft-tissue complications, such as open injury or blisters. Percutaneous screw fixation with limited sinus tarsi incision has shown good functional and radiological outcomes with minimal complications and can be undertaken without delay.


A study sought to use a large total ankle database to identify independent risk factors for the failure of total ankle arthroplasty (TAA) at mid- to long-term follow-up. The investigators employed a prospectively accumulated database to identify all patients who received primary TAA with a minimum follow-up of five years.

The primary outcome was revision, or removal of one or both metal components. Patient and clinical factors examined included age, sex, body mass index, smoking status, presence of diabetes, indication for TAA, implant, tourniquet time and existence of ipsilateral hindfoot fusion. Preoperative coronal deformity and sagittal talar translation were evaluated, along with postoperative coronal and sagittal tibial component alignment. Univariable and multivariable analyses were conducted to identify predictors of TAA failure.

Following exclusion of five ankles that failed due to deep infection, 533 ankles with a mean seven years of follow-up fulfilled inclusion criteria. The results showed that 34 ankles were revised or removed at an average of four years postoperatively, and the sole independent predictors of implant failure were the INBONE I prosthesis and ipsilateral hindfoot fusion.

Practice Management

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The reasons physicians get sued for medical malpractice often revolve around a lack of communication, writes attorney/physician Lee S. Goldsmith, MD, LLB. The No. 1 reason patients approach lawyers is that they are seeking answers physicians do not give. A common refrain is, "I tried talking to my physician, but he didn't answer my calls, the staff didn't put me through and I never received answers." If a patient cannot obtain information from the medical practice, he or she will seek information elsewhere.

Patients often approach an attorney when they cannot pay. Before sending a bill to collection, consider having a member of your office staff call the family and discuss the outstanding bill, which could include working out a payment plan. The third most popular reason for a lawsuit involves a physician's reaction when something unexpected occurs with the patient's outcome. If patients feel that details are missing or that the doctor has not communicated with them sufficiently, they will call an attorney. However, if the doctor speaks to the patient, is honest and shows concern, a lawsuit can often be avoided.

Finally, families may sue out of desperation when a medical injury devastates them financially and emotionally. Although addressing this may not seem like a surgeon's or staff's responsibility, it is in the practice's best interest to make sure a malpractice suit does not happen. Be aware of patients' issues and extend the extra effort to help them out, whether that involves developing a payment plan or referring patients to counseling services to help them cope with illness.


A new study by the RAND Corporation and the American Medical Association (AMA) found that the complexity and speed of change in physician payment models is growing, presenting challenges for physician practices that could affect the quality and efficiency of patient care. An analysis of 31 physician practices in six geographic markets sought to guide systematic efforts by AMA and other healthcare stakeholders to enhance alternative payment models and to help practices adapt to the changes.

Researchers observed an acceleration in the pace of change in alternative payment models from both private insurers and government programs since 2014, partly fueled by the Medicare Access and CHIP Reauthorization Act of 2015 Quality Payment Program. Numerous small and independent practices cited a lack of skills and experience with data management and analysis, and the report found that embedding these methods to help these practices master health data usage would better their odds of success.

In addition, practices increasingly want to avoid the financial risks posed by alternative payment methods, and in some cases they renegotiated contracts with payers to reduce their downside risk or to hand some of that risk to partners, such as hospitals or device manufacturers. The report also suggested that a slower and more predictable rate of change could benefit practices.


In mid-October, the U.S. Department of Health and Human Services' Office of Civil Rights (OCR) issued a press release stating that Anthem would pay $16 million in the largest-ever HIPAA settlement following a massive health data breach. If this could happen to Anthem, which failed to address its HIPAA compliance issues despite having ample resources to do so, it could undoubtedly happen to a solo or small practice group.

For practices to protect themselves against ransomware and other cyberattacks, the first step is to perform a practice-wide risk analysis and proactively address security gaps. It is not enough for practices to simply conduct a risk analysis—the covered entity must also address identified risk gaps and work to close them. Failure to do so could lead to an attack and subsequent penalties. Second, practices should conduct frequent audit trails. Audit trails can help practices determine if someone is attempting to hack in, whether the hack was successful and how to mitigate the hack. While this can take an office manager or physician a significant amount of time, it is still cheaper than fines. Conducting audit trails is also necessary to protect electronic protected health information and to comply with HIPAA.

Third, practices should ensure that written policies and procedures are followed when granting access to staff, vendors and/or software programs. If these do not exist and staff are not trained in them, a practice could be subject to penalties similar to those OCR imposed upon Anthem.

Health Policy and Reimbursement

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About one third of U.S. healthcare payments were tied to value-based care last year, compared to 23 percent in 2015, according to a report from the Health Care Payment Learning and Action Network. The network, a public-private partnership launched by the U.S. Department of Health and Human Services, examined fee-for-service Medicare data. It also studied data from 61 health plans and three fee-for-service Medicaid states on in- and out-of-network spending tied to alternative payment models (APMs), such as shared savings, shared risk, bundled payments and population-based payments.

The report found that 34 percent of healthcare payments, representing about 226 million Americans and nearly 80 percent of the nation's covered populations, came through these two categories of the network's Refreshed APM Framework: alternative payment models built on fee-for-service architecture and population-based payment. That compares to 41 percent of healthcare payments that were based on volume and not linked to quality and efficiency.

In comparing value-based payment adoption across markets, the amount of alternative payment models for commercial, Medicare Advantage, Medicare fee-for-service and Medicaid business lines were 28.3 percent, 49.5 percent, 38.3 percent and 25 percent, respectively. "The report's findings reinforce our understanding that there is sustained, positive momentum in the effort to shift healthcare payments from traditional fee-for-service into value-based payments," said Mark McClellan, co-chair of the network's guiding committee. However, further progress on payment reform is needed, he added.


The White House has proposed an allowance for U.S. workers to use tax-free health reimbursement arrangements (HRAs) to shop for medical coverage in the individual market. The proposal would permit employers to underwrite tax-exempted health reimbursement arrangements to help pay for workers' individual health insurance premiums, reversing the Obama administration's HRA restrictions.

Employers that offer traditional group health coverage to fund an HRA of up to $1,800 annually would also be allowed to remunerate workers for certain medical costs, such as standalone dental benefits or premiums for short-term insurance plans. "This proposal should dramatically increase choices for workers whose employers offer an HRA, and with more consumers in the driver's seat, there will be increased incentive for insurers and providers to deliver high-quality services at affordable prices," said a Trump administration official.


President Trump has announced a plan to overhaul how Medicare pays for certain drugs. The proposal would bypass Congress by using a pilot program to test three ways to lower the costs of drugs—including negotiating for some drugs directly administered by doctors to keep them in line with the far lower prices paid in many other countries, where governments often take an active role in setting prices. The proposal applies only to drugs administered in doctors' offices and outpatient hospital departments and will not affect most prescriptions purchased by patients at pharmacies.

The pricing proposal has several pieces. Under the planned "international pricing index," U.S. drug prices would be benchmarked against 16 other nations where target drug prices are collectively 44 percent lower. Prices would slowly be lowered to international levels over five years. The Trump administration also wants to experiment with letting private sector vendors negotiate with drugmakers. That strategy is modeled on how health insurers negotiate drug prices in Medicare's Part D program, which covers outpatient drugs for older Americans. Under the third branch of the strategy, officials would try changing incentives for doctors to prescribe drugs. Changing the incentive doctors receive to a flat fee, instead of a percentage of a drug's price, could help encourage doctors to use cheaper drugs.

Medicine, Drugs and Devices

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Although opioid prescribing remains at a high level, primary care physicians are prescribing opioids less often while pain medicine specialists and nonphysicians are increasingly prescribing these drugs, according to a new study published in the American Journal of Preventive Medicine. "The substantial variation in prescribing across specialties was surprising," said author Gery P. Guy Jr, PhD, MPH.

The researchers used data from the IQVIAPrescriber Profile for the period of July 1, 2016, to June 30, 2017. The final sample consisted of 970,902 prescribers who had written at least one of 209.5 million opioid prescriptions dispensed during the period. Primary care physicians accounted for 37.1 percent of all prescriptions, nonphysician prescribers—which included physician assistants and nurse practitioners—accounted for 19.2 percent and pain medicine specialists accounted for 8.9 percent. Compared with results from previous research, these new findings "suggest decreases in the percentages of opioids prescribed among primary care physicians and increases among nonphysician prescribers and pain medicine specialists," said Guy.

As the role of nurse practitioners and physician assistants expands, the proportion of opioids they prescribe is expected to increase in the future, said the report's authors. "It is important that prescribing guidelines and education efforts specifically address this population, as they may have differences in training and practice in pain management," they wrote.


The U.S. Centers for Disease Control and Prevention (CDC) reported a 2.8 percent decline in the number of U.S. overdose deaths to an estimated 71,073 people in the year ending in March 2018, compared with the year ending in September 2017. This indicates six straight months of decline, although public health experts caution against making firm conclusions based on this data.

Most fatalities are still driven by opioids overall, with approximately 48,400 deaths recorded from April 2017 to March 2018. However, the number of deadly opioid overdoses slipped 2.3 percent compared with the year ending in September 2017, due to a drop in the number of deaths from both heroin and "natural and semi-synthetic opioids." Despite this, the CDC data indicates that the continuing addiction crisis is not restricted to opioids, and cocaine and stimulants like methamphetamine are causing more than 10,000 yearly deaths.

Experts have forecast that any persistent downturn in overdose deaths would begin with a modest plateauing and then cresting of the curve that measures fatal overdoses over time, and CDC's analysis corroborates that pattern. Northwestern University's Leo Beletsky cites two key insights from these findings. "One is that we are not out of the woods yet, since these rates are still sky high," he says. "[And] we need to be doing much more of what works to get the rates down further."


President Trump has signed into law an opioid package passed by Congress earlier this month to combat an epidemic that led to a record 72,000 drug overdose deaths in 2017. The legislation expands access to substance abuse treatment in Medicaid, provides new federal grants to address the crisis and cracks down on mailed shipments of illicit drugs, such as fentanyl.

The Senate passed the measure by a vote of 98-1 in September after a 353-52 vote in favor in the House of Representatives. The bill had 252 bipartisan cosponsors in the House, more than nearly any other bill in recent years, according to website GovTrack Insider. Trump declared the opioid epidemic a public health emergency last year, which enabled the government to respond more quickly to crises. Some addiction experts, advocacy groups and Democrats, however, urged the administration to do more.