News From ACFAS

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Jump start your educational experience for ACFAS 2020 with this year’s Pre-Conference Workshops! Take your pick from one of these three exceptional workshops being offered on Tuesday, February 18:

Coding and Billing for the Foot and Ankle Surgeon
7:30am-5:30pm | 8 Continuing Education Contact Hours
This interactive workshop will cover pertinent issues related to properly coding surgical procedures and evaluation and management services. Learn how to code efficiently and effectively to see an immediate return on investment in your practice.
Register Now

Diabetic Deformity: Master Techniques in Reconstruction (Cadaveric)
7am-Noon | 4 Continuing Education Contact Hours
Navigate and manage challenging wounds and associated deformities complicating non-healing wounds in the diabetic patient. Get an overview on multiple amputation techniques and surgically managing conditions that contribute to Charcot arthropathy.
Register Now

High Frequency Foot Surgery Techniques (Cadaveric)
Noon-5pm | 4 Continuing Education Contact Hours
Get advanced review of high frequency techniques in an intimate setting with real-time discussion with faculty and fellow attendees. Gain understanding of fixation mechanics and learn how patient recovery and satisfaction varies based on procedure choice and technique.
Register Now

Visit acfas.org/sanantonio to see detailed schedules and to register for a pre-conference workshop. Fellow and Associate members—if you have not already renewed your ACFAS membership for the 2020 calendar year, dues reminders were sent in the mail on October 31. You can pay your dues online now or via mail or fax. Payment is due by December 31, 2019.

Visit the Member Center at acfas.org to learn more about the many benefits your ACFAS membership provides. The Alliance for Wound Care Stakeholders (AWCS) submitted verbal and written comments to the United States Pharmacopeia (USP) advocating that there be a wound care subcategory in the “Dermatological, other” category in the draft Version 8 of the Medicare Model Guidelines. ACFAS is a member of the AWCS. The rationale for USP to create this subcategory is as follows:

1. “Distinguish the products that are used to treat chronic wounds for the Medicare population versus several of the suggested subcategories in Dermatology, which include Acne (very low prevalence in the 65 and up population) and Pediculides/Scabacides also known as Lice Treatment (can be seen as cosmetic and usually less risk than chronic wounds)

2. Minimize Medicare Part D patient discrimination as it currently exists with many other non-comparable products in this category. With no subcategory for wound care, all current and future prescription treatments for wound care might not be included on a Medicare Part D members’ formulary. On page 21 of Section 30.2.1- Formulary Categories and Classes of the CMS Part D Benefits Manual, it states that Part D sponsors are only required to place two drugs in each category/sub-category on the formulary. With a large and diverse “Dermatological, other” subcategory, this could result in a plan could exclude all wound care products on its formulary and still be compliant.”

For more information please contact ACFAS Director of Health Policy and Research Erin Ravelette at erin.ravelette@acfas.org. Students and residents, are you trying to decide which practice type is a best fit for you? Are you interested in hearing insight on common malpractice issues and understanding the complex intersection of law and medicine? Mark your calendars for two complimentary webinars scheduled in November:

Don't Be an Outlaw: Learn to Wrangle Malpractice Mysteries
Thursday, November 7
8pm CT
Register Now

Practice Models: Which Model Fits You Best
Thursday, November 14
8pm CT
Register Now

Foot and Ankle Surgery

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The purpose of this Level I study was to determine whether postoperative ketorolac reduces opioid consumption, improves Visual Analogue Scale (VAS) pain control and affects fracture healing after the open redaction and internal fixation of ankle fractures. Between August 2016 and December 2017, 128 patients undergoing open redaction and internal fixation of ankle fractures were randomized to treatment with or without ketorolac. A once-daily survey was distributed via email for a week after the surgery, asking unblinded participants to report their daily opioid consumption, pain level and sleep interference using the VAS, as well as their pain frequency using a five-point Likert scale and side effects with the VAS. Eighty-three percent of patients completed all seven postoperative surveys. Fifty-six patients received ketorolac with opioid (treatment group) and 50 received opioids alone (control group). The treating surgeon assessed clinical healing based on the patient's ability to ambulate comfortably at 12 weeks postoperatively.

Radiographic healing was assessed by two foot and ankle surgeons blinded to the patient's name and time since surgery. The study found that patients in the treatment group consumed a mean of 14 opioid pills, lower than the mean of 19.3 pills consumed by patients in the control group and had lower median VAS scores for pain on the first and second days after surgery. Patient-reported pain scores and scores for sleep did not show a benefit to the use of ketorolac, and there was no difference between the groups in terms of clinical healing and radiographic healing. The authors conclude that adding ketorolac to the postoperative regimen helped patients manage postoperative pain with less narcotic analgesia, but could not determine the true safety of this drug in terms of fracture healing and side effects.


The study aims to define peroneus tertius syndrome, in which the peroneus tertius tendon causes catching or locking over the anterolateral ankle or rearfoot with accompanying pain. It presents a retrospective involving four patients diagnosed with this syndrome, discuss symptoms, review radiographic imaging and outline a minimally invasive operative technique for the resection of the symptomatic tendon. It also evaluates postoperative outcomes and satisfaction scores after surgical management.

All patients experienced symptom resolution by the fourth postoperative week, with statistically significant improvement in visual analog scale scores. Overall patient satisfaction was 100 percent, with improved functional status and no recurrent symptoms at final follow-up. These findings show that excision of a symptomatic peroneus tertius resolves symptoms, facilitates a quick return to activity and has strong patient outcomes. The study's authors recommend that peroneus tertius syndrome be considered as part of the differential diagnosis when evaluating anterolateral ankle or rearfoot pain.


The authors performed a comprehensive literature review on continuous popliteal sciatic nerve block (CPSNB), which has been performed in outpatient foot and ankle surgery as a regional anaesthesia method to relieve postoperative pain. They aimed to validate the efficacy of CPSNB with regards to better pain relief and reduced analgesics consumption and to assess the safety of CPSNB. To do so, they reviewed five randomized controlled trials that compared the efficacy and safety of CPSNB with the single-injection popliteal sciatic nerve block group. Primary parameters were visual analog scale (VAS) scores at postoperative 24, 48 and 72 hours, and the secondary outcome parameters were the amount of oral analgesics consumed, overall patient satisfaction and the need for post-surgery admission.

Compared to the single-injection group, CPSNB was associated with a lower VAS score at postoperative 24 and 48 hours, with no neuropathic symptoms or infection events after the nerve block. However, there were several minor complications associated with the pump and catheter system, most commonly drug leakage. The authors conclude that CPSNB is effective in pain management for outpatient foot and ankle surgery, and both methods appear to be safe, though further research is needed.

Practice Management

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Practices will increasingly rely on strong marketing initiatives for viability and growth. This starts with knowing the market, often by conducting a marketing study and then determining how a practice can differentiate itself from its competitors. A competitor messaging analysis can help in this process. Practices should audit their own websites for clarity and ease of access, ensuring the site contains prominent patient testimonials, physician headshots and bios and insurance policies. Practices should also create a search engine optimization and social media plan, making it easier to be found by potential patients and may want to maintain some presence as a media expert by connecting with local journalists.


Sen. Brian Schatz (D-Hawaii) has introduced a bill that would expand telehealth services through Medicare. Schatz says the goal of the Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act of 2019 is to improve health outcomes, ease access to doctors and lower costs for patients and providers. The bill also includes provisions that would eliminate geographic and originating site restrictions for services like mental health and emergency medical care, enhance the ability of rural health clinics to provide telehealth services and allow the secretary of Health and Human Services to waive telehealth restrictions when necessary. The bill has the support of a bipartisan group of senators and over 100 organizations. A companion bill has also been introduced in the House of Representatives.


Secondary or supplemental work is becoming increasingly popular among physicians, but the medicine and healthcare industries are being placed under greater scrutiny. This makes it important for practicing physicians to fully understand the rules and guidelines regarding side jobs. Failure to do so could result in harsh financial penalties and the loss of a job. However, when done properly a side job can be successful, if it has planned carefully. Experts recommend keeping communication lines open regarding a side job so no one is surprised or caught off guard by the discovery of a side job. Doctors also say it is important that a side job not take away attention and time from a primary practice. Partners and co-workers could have reservations about a decline in outcomes and care that a side job could create. Other issues to consider by doctors and care organizations include profit income sharing, contractual issues and medical liability.

Health Policy and Reimbursement

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The Committee for a Responsible Federal Budget (CRFB) has released a paper providing its preliminary estimates for various ways to finance "Medicare for All." The budget watchdog group notes that there are several ways that policymakers could finance the $20 trillion cost of Medicare for All, a single-payer health care system that eliminates premiums and deductibles. CRFB presented several options, including a 32 percent payroll tax, a 25 percent surtax on income above the standard-deduction amount, a 42 percent value-added tax, mandatory premiums averaging $7,500 per capita and more than doubling all individual and corporate tax rates.

The group estimated that raising taxes on the wealthy would not be enough to fully finance Medicare for All. CRFB also said that Medicare for All could be financed by cutting all non-health spending by 80 percent, increasing the national debt to 205 percent of gross domestic product. The group noted that the financing options it listed could be combined, and that policymakers could reduce the cost of the program. CRFB noted that most of the financing options it listed would be more progressive than current law, but most would also shrink the US economy.


As open enrollment begins for employer-provided health insurance coverage, some employees are seeing traditional plans offered alongside or instead of plans with sky-high deductibles that may have been their only choice in the past. Offering more generous plans with lower deductibles is one recruitment tool employers are turning to in a tight labor market, but some workers prefer paying a higher premium for a more traditional plan with more predictable out-of-pocket costs. A survey of large employers by the National Business Group on Health reveals that only 25 percent of firms will offer high-deductible plans as the sole option in 2020, down 14 percentage points from two years ago. Meanwhile, a Kaiser Family Foundation survey found that 58 percent of covered employees worked at companies that offered at least one high-deductible plan in 2019.

Traditional plans like PPOs give employers more flexibility to try different approaches to improve employees' health, said Tracy Watts, a senior partner at benefits consultant Mercer. Watts noted, "Some of the newer strategies that employers want to try just aren't [health savings account] compatible."


A report from the Georgetown University Center for Children and Families shows the number of uninsured children in the United States rose for the second consecutive year and has surpassed 4 million, the highest level since the Affordable Care Act (ACA) was implemented. Between 2016 and 2018, the number of uninsured children rose by more than 400,000, and that increase has eliminated much of the coverage gains since the health law was enacted, due in part to policies pushed by the Trump administration and congressional Republicans. The report cited, among other things, the move to significantly reduce ACA outreach and enrollment grants while shortening the open enrollment period. Based on U.S. Census Bureau data, the report found seven states where the uninsured rate for children increased most sharply and only one state that recorded improvements during the two-year study period. The majority of uninsured children are eligible for Medicaid or CHIP but are not currently enrolled.

Medicine, Drugs and Devices

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A new US Food and Drug Administration (FDA) report outlines what officials see as the underlying causes of ongoing drug shortages. The drugs in question are mostly generic sterile injectables, and current market-based solutions are struggling to maintain high-quality supplies of these medically necessary but low-volume drugs with no sales growth prospects. The report notes that the drugs are something of an economic anomaly, as prices did not rise when shortages began and production did not increase enough to restore supply to pre-shortage levels during shortages. Many manufacturers discontinued the production of drugs before a shortage for commercial reasons, suggesting what officials call "a broken marketplace" where drug scarcity does not result in the price increases predicted by basic economic principles.

The report also points to the complexity of drug supply chains and the lack of monetary incentives for companies to maintain high quality standards. The report indicated that for-profit companies find it increasingly unrewarding to produce low-volume drugs, as when one of the few suppliers for such drugs stops production for some reason, others do not necessarily step in to fill the void. The report noted considerable barriers to market entry in drug manufacturing given the number of regulatory hurdles and the high amount of investment required. FDA suggested three general approaches to resolve these issues, the first being better data collection and analysis to identify risk factors for shortages. In addition, rating systems for "quality management maturity" could help identify producers with especially robust quality-control practices that allow them to maintain uninterrupted production. The report also suggested new contracting structures, such as contracts under which drug buyers guarantee minimum purchase volumes and "fair prices" while producers work to establish "supply chain redundancies."


Facebook has rolled out a new tool for tracking preventive health screenings that might be recommended for users, based on age and sex. The Preventive Health feature concentrates on cardiovascular health, cancer screening and seasonal flu, developed in collaboration with the American Cancer Society, American College of Cardiology, American Heart Association and U.S. Centers for Disease Control and Prevention. The tool is accessible by either seeking it on Facebook or clicking on a promotion that might be displayed in newsfeeds.

Preventive Health delivers personalized recommendations to be considered by users, as part of their preventive care strategy. The tool also provides a map of federally qualified health centers, where anyone can go to receive certain screenings, tests and other healthcare services, provided irrespective of patients' ability to pay and charged on a sliding fee scale.


Hospitals could soon face shortages of surgical tools because several plants that sterilize the equipment have been shut down. The U.S. Food and Drug Administration (FDA) highlighted the issue in a Friday statement, saying shortages could last years and compromise patient care. The warning follows the recent closure of several sterilization facilities that use ethylene oxide, which can be hazardous at elevated levels and is increasingly be scrutinized by state health and environmental officials. Sterilization is a daily process at many healthcare facilities and involves various methods, including heat, steam and radiation. However, the oxide gas is the only method for cleaning many devices from plastic, metal or glass, and about half of all sterilized medical devices in the United States are cleaned with it.

Exposure to dangerous levels of ethylene oxide can cause cancer, and factories that emit the gas are subject to safety standards under both state and federal environmental laws. Earlier this year, Illinois authorities closed a plant owned by sterilization company Sterigenics after detecting high outdoor levels of the gas. Another Sterigenics plant in Georgia has been closed for maintenance since August after state officials detected potentially dangerous emissions at the facility. The FDA will discuss new sterilization techniques at a meeting next month.