News From ACFAS

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Don’t miss your chance to showcase your latest research in poster format at ACFAS 2021, May 18-21 in Las Vegas. Help develop this year’s poster program and advance the profession by presenting your recent studies in foot and ankle research.

Poster abstracts for this year must be submitted to ACFAS by January 13 to be eligible for review. PDFs of eligible posters are due March 3.

Visit acfas.org/PosterSubmission to view submission guidelines/criteria and submit your poster today! It’s not too late to pay your ACFAS membership dues for 2021! Even though the December 31 deadline has passed, the College has made the process easy to still renew your membership—plus, any potential late fees are being waived for 2021.

Renew your membership online or contact the College at (773) 693-9300 to pay over the phone during office hours of 8:30am–5pm CT. Please reach out to the Membership Department at membership@acfas.org if you need an invoice or receipt, have any questions about your membership benefits or need additional assistance.

Remember—ACFAS is here for you and we’re stronger together. Renew your membership today so we can tackle 2021 side by side. Another chance to get the A to Zs in foot and ankle research is coming your way. Register now for what's next in the ACFAS Virtual Journal Club series set for Thursday January 21 at 7pm CT. This installment is hosted by the University of Maryland Limb Preservation and Deformity Correction Fellowship and presented by Jacob Wynes, DPM, MS, FACFAS and Korey Dubois, DPM.

Register now at acfas.org/JournalClub, where you can also access archived ACFAS Journal Club Sessions.

Foot and Ankle Surgery

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Mini implants are increasingly used in foot and ankle surgery. They preserve the joints' functions, are easy to insert and easy to convert to an alternative treatment. Early surgical attempts using silastic implants did not bring the anticipated success. The first achievements were realized with modern metallic mini implants in the first metatarsophalangeal (MTP) joint and the ankle joint. For a few years now, a polyvinyl alcohol implant has been used to treat the arthritic first MTP joint. Even severe arthritic joints can be treated with an implant made of polylactide.

This implant can also be used in the treatment of Lisfranc joint pathologies. To address severe osteochondral defects of the talus, an innovative hemiarthroplasty implant has been suggested. Researchers examined currently used mini implants. Their application as possible alternatives to total joint replacement or joint fusion was critically reviewed in light of the current literature.


Researchers sought to develop a system for people with amputation that non-invasively restores missing control and sensory information for an ankle-foot prosthesis. In their approach, a wrist exoskeleton allows people with amputation to control and receive feedback from their prosthetic ankle via teleoperation. The researchers also implemented two control schemes: position control with haptic feedback of ankle torque at the wrist and torque control that allows the user to modify a baseline torque profile by moving their wrist against a virtual spring. They measured tracking error and frequency response for the ankle-foot prosthesis and the wrist exoskeleton.

To demonstrate feasibility and evaluate system performance, they conducted an experiment in which one participant with a transtibial amputation tracked desired wrist trajectories during walking, while we measured wrist and ankle response. Benchtop testing demonstrated that for relevant walking frequencies, system error was below human perceptual error. During the walking experiment, the participant was able to voluntarily follow different wrist trajectories with an average RMS error of 1.55 degrees after training. The ankle was also able to track desired trajectories below human perceptual error for both position control (RMSE = 0.8 degrees) and torque control (RMSE = 8.4 percent).

The researchers concluded that the system allows a user with amputation to control an ankle-foot prosthesis and receive feedback about its state using a wrist exoskeleton, with accuracy comparable to biological neuromotor control. This bilateral teleoperation system enables novel prosthesis control and feedback strategies that could improve prosthesis control and aid motor learning.


Ankle osteoarthritis (OA) can cause disabling symptoms, and some patients prefer to be treated with minimally invasive procedures. The aim was to evaluate the efficacy and safety of a single intraarticular injection of platelet-rich plasma (PRP) for patients with ankle OA. In a prospective study done in a university-affiliated tertiary care medical center, 44 patients with symptomatic ankle OA for at least six months were recruited. Patients received a single injection of PRP (3 milliliters) into symptomatic ankles. The primary outcome was the change from baseline in the visual analog scale (VAS) pain (0-10 centimeters) at six months.

Secondary outcomes included the Ankle Osteoarthritis Scale (AOS) score, American Orthopaedic Foot and Ankle Society (AOFAS) hindfoot-ankle score, single leg stance test (SLS), rescue analgesics consumption and patient satisfaction. Thirty-nine participants (88.64 percent) completed the study. Significantly improvement in the VAS and AOS was noted at one, three and six months follow-ups. The mean VAS pain decreased significantly from 4.1 (inclusive range of plus or minus 1.7) at baseline to 2.2 (plus or minus 1.9), 1.7 (plus or minus 1.5) and 1.8 (plus or minus 1.6) at one, three and six months. The mean total AOS score reduced by 1.5, 2.2 and 2.1 from baseline respectively postinjection. The mean AOFAS hindfoot-ankle score improved from 80.3 points at baseline to 87.2, 91.6 and 89.7 points at one, three and six months. SLS tests improved significantly at each follow-up. Acetaminophen consumption dropped significantly, and no serious adverse events occurred. The study showed promise for a single intraarticular injection of PRP in the treatment of ankle OA.

Practice Management

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Concord Technologies Chief Commercial Officer John Harrison writes that the most frequent root causes of medical errors are communication problems and inadequate information flow, often due to a reliance on paper-based fax communication. "Moreover, documents—whether printed or stored on a workstation or server—still require manual data entry into [electronic heath records (EHRs)] and practice management systems," he explains. What is needed is a document exchange and processing approach to facilitate fully digital, secure and efficient communication among customized EHRs, each with its own individual workflows and document processing preferences. This demands full digitization, which healthcare organizations can realize by either substituting digital fax for traditional fax or scanning documents into the system. The resulting format is often a TIFF image, which enables paperless filing of clinical documents to the EHR. Rendering the document into a readable format, like a searchable PDF, also allows the organization to add value in processing at every subsequent step. "Making the document readable enables automatic identification of the type of document, data extraction, including patient name, medical record, date of birth and physician name, as well as more effective management of the overall lifecycle of the document," Harrison writes. "This step requires the utilization of [artificial intelligence] and natural language processing techniques."


Having a proven revenue cycle partner takes on particular urgency right now for physician practices, which are eager to maintain patient satisfaction as COVID-19-related financial struggles, loss of insurance and other obstacles challenge where and how they receive care. To be successful, practices will need to carefully select a partner with the right technology, know-how and best practices in place. One of the three primary advantages of such a relationship is access to specialized talent and systems, including billing and coding operations as well as claims and correspondence management.

A solid revenue cycle partnership can also facilitate safe, contactless solutions that allow doctor practices to connect with patients during the pandemic — i.e., electronic appointment scheduling and management, pre-registration and digital payments. Additionally, with many Americans requiring alternative payment arrangements at this time to pay for care, a revenue cycle partner can help practices identify appropriate funding sources, handle prior authorizations quickly and perform eligibility checks early for the purpose of estimating the costs of services and flagging patients who may require supplemental funding.


The end of the calendar year is an opportune time for physicians to review their financial affairs, writes Jeff Witz, who helps doctors manage their wealth. There is no time better than now, for instance, to update accounts and check on progress toward fiscal objectives that were set at the onset of 2020. Especially given this year’s unique circumstances, Witz also recommends that physicians also make sure their emergency funds — which ideally house enough cash to take care of basic needs for three months in case of an unforeseen circumstances — are up to snuff. For single-income households, the bar rises to a six-month cache for emergencies. If that money was needed in part or in entirety in 2020, Witz warns against waiting too long to start building those funds back up.

As end-of-year deadlines approach, he also encourages physicians to maximize contributions to their 401(k) and IRA retirement accounts as well as spend any money still left in healthcare and/or dependent care Flexible Spending Accounts. Other recommendations including contributing to children's 529 college education accounts, designating persons who are to receive gift assets, updating life insurance and retirement account beneficiaries and donating to charitable causes.

Health Policy and Reimbursement

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New research published in the New England Journal of Medicine reveals that in Los Angeles, for instance, hospitals with clinical quality above the national median allocate just 23 percent of inpatient days to individuals with Medicaid coverage, as compared with 54 percent of inpatient days for hospitals in the bottom two quality quartiles. Additionally, more than 80 percent of white Americans were covered by an employer or Medicare as of 2018, compared with only 62 percent of Black Americans and 52 percent of Hispanic Americans.


The US Court of Appeals for the District of Columbia Circuit upheld a White House-backed rule to require hospitals to disclose the prices they negotiate with insurers for many types of common tests and procedures. Several hospital groups challenged the rule, which was issued in November 2019 and was scheduled to take effect on January 1. The groups warned that the rule would divert critical resources from hospitals to compile healthcare costs while reducing competition and causing confusion about patients' out-of-pocket expenses.

Medicine, Drugs and Devices

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The US Centers for Disease Contrl (CDC) released its opioid prescribing guideline on March 15, 2016, and researchers with Missouri's Saint Louis University School of Medicine were curious about the subsequent effect, if any, on orders for Schedule II opioids. A cross-sectional study examined data from 279,435 de-identified adults in a commercial claims database, all of whom had a non-cancer painful condition. Investigators specifically looked at the volume of new prescriptions for Schedule II opioids, which are associated with a high risk of potential abuse, compared with tramadol, a Schedule IV opioid with lower abuse potential, in the 18 months before and after the CDC guidance was issued. Analysis revealed that with the exception of a 14 percent decrease in the likelihood of patients receiving oxycodone vs. tramadol, the odds of new prescriptions for Schedule II opioids did not change significantly after publication of the CDC recommendations—even among patients at high risk for opioid misuse due to depression, anxiety, substance abuse disorder or benzodiazepine use.