News From ACFAS

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We’ve officially kicked off ACFAS 2020 and we’re taking over the Henry B. Gonzalez Convention Center in San Antonio this week! The preconference workshops were a hit and we’re looking forward to another fantastic conference!

We have a full afternoon of educational sessions ahead covering trending topics in foot and ankle, diabetic foot, forefoot and midfoot reconstruction and two cadaver workshops. Tonight, music and excitement await as we experience #ACFAS2020 Texas-style with the Premier Connection Opening Reception.

This year’s conference is guaranteed to bring non-stop action, and we can’t wait to share the #ACFAS2020 experience with you! Congratulations to new ACFAS President Scott C. Nelson, DPM, FACFAS; Thanh Dinh, DPM, FACFAS, President-Elect; Michael J. Cornelison, DPM, FACFAS, Secretary-Treasurer and Christopher L. Reeves, DPM, MS, FACFAS, Immediate Past President.

The new officers will take office tomorrow, February 20 during the Awards Ceremony and Business Meeting at ACFAS 2020 in San Antonio along with new and returning board members:

Eric A. Barp, DPM, FACFAS
George T. Liu, DPM, FACFAS
Christopher D. Lotufo, DPM, FACFAS
Alan Ng, DPM, FACFAS
Matthew E. Williams, DPM, FACFAS
Alan A. MacGill, DPM, FACFAS
Barry Rosenblum, DPM, FACFAS

We’d like to thank our retiring board members, John S. Steinberg, DPM, FACFAS; Meagan Jennings, DPM, FACFAS; Harry P. Schneider, DPM, FACFAS and Randal L. Wraalstad, DPM, FACFAS for their steadfast dedication and service to the College. Congratulations to Greg Still, DPM, FACFAS on being selected to receive the 2020 ACFAS Distinguished Service Award! Dr. Still will be presented with the award tomorrow during ACFAS 2020 in San Antonio.

This prestigious award is presented each year to a member whose service to the College and wide range of volunteer roles go far beyond the call of duty.

“Greg’s passion is evident through the number of committees he’s served and the volunteer work he’s done both inside and outside of the College, ACFAS President Christopher Reeves, DPM, MS, FACFAS shared. “His dedication and drive to educate and help others is an example to anyone wanting to be more involved in advancing the profession and care of the patients we serve. He is the embodiment of selflessness and compassion and I am so honored to present this award to him.”

You can read more about Dr. Still’s commitment to service and the College in the next issue of ACFAS Update.

Foot and Ankle Surgery

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The study investigated the biomechanical characteristics and stabilizing contribution of the bifurcate ligament, using a multidirectional loading method and assessing the stabilizing effect of a brace after ligament injury. Eight cadaveric feet were tested for forefoot torque in inversion, eversion, adduction and plantarflexion, and each band of the bifurcate ligament was transected sequentially. Stability decreased substantially after calcaneocuboid ligament transection for inversion and adduction loading. Bracing restored some stability but had only limited effect on the adduction loading direction. The findings indicate that inversion and adduction loading are strongly related to bifurcate ligament injury, though the ankle brace may have limited a stabilizing effect for loads under adduction.


Researchers performed a prospective comparison study of orthopedic trainees and attending services to determine if three-dimensionally (3D) printed fracture models can improve orthopedic trainee education. Sixteen resident trainees and five attending surgeons rotated through workstations viewing computed tomography images and either a digital 3D volume rendering or 3D printed model of the fractured calcaneus. A standardized questionnaire was used to compare diagnosis, time for evaluation, confidence of fracture understanding, perceived model accuracy and proposed treatment.

Junior residents had the slowest time of assessment and lowest percentage of correct diagnoses, though these findings did not reach significance. Residents displayed higher levels of confidence in fracture understanding with increasing residency year of training, and this confidence was greater for cases that included a 3D printed model. Perceived accuracy of cases with 3D printed models was significantly higher than cases without 3D models. The study finds that 3D printed models increase the perceived accuracy of fracture assessment, though there was no statistically significant improvement in diagnostic accuracy. The 3D printed models did improve trainee confidence, although this effect diminished with increasing residency year.


This series reports on outcomes and identifies predictors for success following particulated juvenile cartilage allograft transfer (PJCAT) as a treatment for isolated osteochondral lesions of the talus (OCLTs). Data were collected from 33 consecutive patients who underwent PJCAT by the same surgeon from 2013 to 2017 with a mean 3.5 years of follow-up, accounting for preoperative demographic factors and OCLT morphologic data. Outcomes included postoperative improvements in VAS and American Orthopaedic Foot and Ankle Society (AOFAS) score and clinical success/failure.

Improvement in ankle pain VAS following isolated PJCAT was 51 percent, and 40 percent of the first 16 consecutive patients in whom complete AOFAS scores were available saw improvement. Presence of at least one behavioral health diagnosis was a risk factor for decreased pain relief, while moderate to severe preoperative pain predicted improved postoperative pain relief. Age, BMI, tobacco use and OCLT morphology did not affect outcomes.

Practice Management

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Creating a personalized practice manual can be a good way to centralize and standardize important practice information, policy and procedures while making staff members more independent. Employed physicians can use a practice manual to augment their company's manual, reflecting their personal practice style and preferences. A typical practice manual opens with a table of contents and goes on to cover important practice information, such as a mission statement, a brief summary of the practice and all utility companies with account numbers and contact information so staff can deal with any utility-related problems.

The next section should cover employee information, including details about each staff position and expectations for time and attendance and covering various employee policies. You may want to include input from staff members on this section, asking each to write up their own job description with the tasks they do on a daily basis. Next, cover clinical policies, providing information on how to deal with office emergencies, a list of all the tests you do in-house and office policy on medication refills, controlled substances, test results and scheduling appointments.

This section should also be used to describe how you want patient information documented in the medical record. Another section in the manual should detail office policies on safety, including OSHA guidelines, workman's compensation details and the proper handling of biomedical waste, as well as policies on protecting healthcare information.


The article provides some strategies to promote physician retention, preventing costly turnover that can eventually bring down a practice's reputation. Retention begins with recruitment, so it is important to be honest about the workload and the type of patient care that is usually seen in the practice. Physicians are often disappointed when the real job does not match the advertised job, so being dishonest about a position is not worth the resulting disillusionment and mistrust that can develop as the truth starts to unfold. Treat other physicians with respect, taking each employee's needs and opinions into consideration. Disrespect can manifest as a skewed call schedule, an unfair financial arrangement, weak support staff allocation, undesirable workspace and unresponsiveness in communicating, all of which can make a physician feel angry and dissatisfied, leading to turnover.

Moreover, if those who seem like they might tolerate disregard for their concerns are treated worse than those who demand attention, the trend will be obvious to everyone and overall morale will suffer even among highly valued employees. Listening and attentiveness go a long way in promoting retention and creating a pleasant workplace. A physician who avoids conflict by avoiding issues that need to be addressed will be seen as weak by partners, who may ultimately leave for a more professional setting. Finally, when a physician does leave, which can happen for many reasons unrelated to the practice, it is always better for morale to be open about the impending transition.


Managers can make giving their employees feedback more comfortable with a few strategies. Feedback should be short, specific and frequent, taking the form of an ongoing conversation instead of staying within the confines of an annual performance appraisal. Target your feedback to specific actions and areas of expertise and try to build on existing skills instead of delivering "constructive criticism," as research finds that telling people how to improve can backfire. Neurological research finds that people grow more in their areas of greater capability, so it is more effective to capitalize on what staff do well and focus on leveraging their strengths more effectively. Be careful about your word choices so as not to trigger a "fight or flight" response, which limits the brain's ability to learn.

Frame statements and questions in the first-person to provide an opportunity for a productive conversation to unfold. Additionally, it is important to understand the difference between instructional feedback, which is concrete and fact-based (such as a specific error made) and performance feedback, which has to do with subjective traits such as an employee's productivity, supervisory skills or problem-solving abilities. These areas can be more difficult as data show that, in what is known as the Idiosyncratic Rater Effect, 61 percent of how you rate staff is actually a reflection of your own characteristics, not theirs. Delivering performance feedback is more challenging and takes some practice, so it is important to learn from each conversation and be open to opportunities for continuous improvement.

Health Policy and Reimbursement

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Under a recently released guidance document from the US Centers for Medicare and Medicaid Services (CMS), Accountable Care Organizations (ACOs) participating in a Medicare Shared Savings Program under two-sided risk who have selected prospective payment can now remove geographic limitations normally applied to fee-for service plans. This will allow beneficiaries to receive certain telehealth services at home. While all ACOs in two-sided risk models who use prospective assignment can use telehealth, the new CMS guidance gives more leeway to ACOs at risk of paying money back to CMS because they have not hit their spending targets on patients for which they are financially responsible.


President Trump's proposed budget includes close to $1 trillion in cuts to Medicaid and the Affordable Care Act (ACA). According to the budget, $844 billion would be cut over 10 years from the “President's health reform vision,” a stand-in for the repeal and replacement of ACA. An additional $150 billion would be cut from implementing Medicaid work requirements and other changes to the program. Democrats rebuked those proposed cuts. Liberals pointed out that President Trump vowed not make cuts to Medicaid during his 2016 campaign. A Trump administration official said the Medicaid cuts will help preserve the program for Americans who need it the most like children, the disabled, elderly and pregnant women.


According to a new US Centers for Disease Control and Prevention (CDC) study, the percentage of people in families struggling to pay medical bills fell to about 14 percent in 2018 from nearly 20 percent in 2011. However, that figure is only slightly less than what it was in 2016 and 2017. Researchers said the smaller decline reflects broader health care trends, including a slowdown in growth for the Affordable Care Act's coverage expansion.

Medicine, Drugs and Devices

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The US Centers for Disease Control and Prevention (CDC) has issued guidance recommending the use of personal protective equipment (PPE) for healthcare personnel caring for patients with confirmed or possible Wuhan coronavirus infection. Healthcare personnel should adhere to Standard, Contact and Airborne Precautions when doing so, which includes the use of PPE such as N95 resspirators, gowns, gloves, face shields and eye protection. Patients with confirmed or possible infection should wear a facemask when being evaluated medically. For the general public, CDC does not recommend the use of facemasks or respirators.


New draft guidance released by US Food and Drug Administration (FDA) discusses how the agency will speed up its review of biosimilar or interchangeable application supplements. The new draft notes, among other things, that FDA cannot license a biosimilar or interchangeable product for an indication protected by orphan-drug exclusivity or pediatric exclusivity until the expiration of that exclusivity. The draft also explains how the proposed labeling for a biosimilar will depend on whether the applicant is seeking licensure for all or fewer of the conditions of use licensed for the reference product.


A new single-center restrospective study published in JAMA Surgery found that mandating surgical jackets and bouffant caps in the surgical suite did not reduce patients' infection risk. Researchers analyzed all 34,042 inpatient operations at the University of Alabama at Birmingham Hospital over a 22-month period as the center transitioned to use of bouffants and jackets. Surgical site infections were similar across surgical attire groups: 1.01 percent of patients were infected without either, 0.99 percent were infected with bouffant headgear alone and 0.83 percent were infected with both items. Mortality, sepsis and wound dehiscence also did not differ significantly by attire. Surgical jackets were estimated to cost the center more than $300,000 annually, though bouffants were actually cheaper than surgical skull caps.