News From ACFAS

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Tune into our latest podcast release, “Inside Out Ankle Stabilization,” and hear a panel of your peers debate the pros and cons of arthroscopic versus open and limited techniques to stabilize the ankle.

Panelists share their own personal experiences using each approach and offer insights into how instrumentation, biologics and other factors will shape the future of ankle repair.

Access the podcast now through the ACFAS e-Learning Portal, and visit acfas.org/e-learning regularly for other new free products to help you earn CME at your convenience. If you are a fellowship program director and would like to seek ACFAS status for your program, submit your application by May 1, 2019.

The ACFAS Fellowship Committee will meet in mid-August in Chicago to review any new applications and will communicate their decisions later that month.

Contact Michelle Kennedy, ACFAS director of Membership and Post Graduate Affairs, to request an application or to learn more about the College's Recognized Fellowship Initiative. The ACFAS Fellowship Committee recently granted approved status to the following fellowship program. The program was granted Conditional Status with ACFAS since they have not yet had a fellow matriculate through:

University of Maryland Limb Preservation and Deformity Correction Fellowship
Location: Baltimore
Program Director: Jacob Wynes, DPM, MS, CWS, FACFAS
acfas.org/fellowshipwynes

All Conditional Status programs are considered for Recognized Status with ACFAS after they have received status and the first fellow completes the program.

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org/fellowshipinitiative to review a complete listing of programs and minimal requirements.

Foot and Ankle Surgery

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A study was conducted to assess the clinical and radiographic results of a double arthrodesis technique for the treatment of equino-plano-valgus foot deformity in pediatric patients with cerebral palsy. A retrospective evaluation was performed on 175 feet surgically treated with a talonavicular and calcaneocuboid joint fusion technique. Average age at surgery was 14.7 years, and the visual analogue scale for pain score, Gross Motor Function Classification System scale, talonavicular angle, Costa-Bertani angle and Kite’s angle on standard weightbearing radiographs were assessed preoperatively and postoperatively. Average clinical follow-up was 62.4 months.

The mid Gross Motor Function Classification System scale value had no significant improvement in any of the subgroups considered. A significant improvement in the visual analogue scale for pain score value manifested six months post surgery, while radiographic examination showed a statistically significant improvement in the talonavicular angle and the Costa–Bertani angle. Complications ensued in 8.6 percent of cases.


A study was conducted to evaluate the average time to return to training and official game participation after modified Broström operation (MBO) in elite athletes. Sixty athletes, average age 19.3 years and diagnosed with lateral ankle instability, underwent MBO from October 2011 to December 2013. The surgical procedure involved was anterior talofibular ligament imbrication with reinforcement of the inferior extensor retinaculum. The average follow-up time was 28.8 months. Patients were divided into an early return to play (RTP) group and late RTP group, which were compared to identify possible risk factors affecting the RTP time.

The average length of time to return to personal training was 1.9 months, return to team training was 2.9 months and return to competitive play was 3.9 months. No significant differences of any variables, including age, sex, body mass index, level of sports, grade of instability, presence of os subfibulare and preoperative functional score, were observed between the early RTP and late RTP groups.


A retrospective comparative cohort study was conducted over two years to analyze whether early postoperative full weightbearing following syndesmotic ankle fixation affected radiographic outcomes suggestive of diastasis. A total of 152 consecutive patients sustaining an unstable ankle fracture requiring syndesmotic stabilization were included, with 86 eventually analyzed. The median patient age was 36, with 54 males and 32 females. Median follow-up was 12 weeks. No significant difference was observed when comparing weightbearing status and change in radiographic measurements intraoperatively compared to six- and 12-week follow-up radiographs.

Practice Management

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Key aspects of the U.S. Centers for Medicare and Medicaid Services' 2019 MACRA rule for the Quality Payment Program that physicians should be aware of include additional exemptions, with the inclusion of a third low-volume threshold. Moreover, a shift in Merit-Based Incentive Payment System (MIPS) category percentages has occurred, with the quality performance category upgraded from 50 percent to 45 percent of a physician's score. In addition, payment adjustments will range from -7 percent to 7 percent in the 2021 payment year, and physicians now require certified electronic health records.

The five-point bonus for treatment of complex patients remains unaltered, while bonuses awarded to small practices will be incorporated into the quality performance category instead of remaining standalone bonuses. The 2019 revision will allow physicians to opt in to MIPS if they meet one or two of the low-volume exemptions, and more clinician types now qualify for MIPS.


To improve their staff's engagement, physician practices could implement MAGIC (Meaning, Autonomy, Growth, Impact, Connection) principles. As leaders, practice managers should remind employees what their work means, and not just those involved directly with patient care. Autonomy means workers have the ability to "shape your work and environment in ways that allow you to perform at your best." Meanwhile, growth is defined as extending oneself and improving, which could take the form of cross-training employees to learn new skills, mentoring new employees or letting someone lead a committee.

Impact concerns helping employees know their effect on the work they do for the workplace, coworkers or patients. Finally, connection is described as a "sense of belonging to something beyond yourself." When connections are established, employees are motivated to work toward the mission of the organization because they feel they are a core element.


Boston-based Nuance is testing an ambient listening system that, without requiring a mouse or keyboard, can transcribe a conversation between a doctor and patient and can upload key portions of it into a medical record. The product is a rectangular box with 16 microphones and a motion-detection camera, which is mounted on the wall of an exam room to record patient encounters and automatically load key details into corresponding fields within the medical record. If validated, the solution would be a significant advancement in the use of voice technology in clinical care, enabling instant documentation of patient visits and less interference from computers with the doctor-patient relationship.

Nuance plans to initially introduce the technology in orthopaedics, dermatology, podiatry and other specialities where patient visits tend to be more structured and focused on a predictable set of issues. The system is being trained on hundreds of thousands of recordings of patient visits.

Health Policy and Reimbursement

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The White House is considering whether to require hospitals, doctors and other healthcare providers to publicly disclose the negotiated prices they charge insurance companies for services. The U.S. Department of Health and Human Services is seeking public comment on whether patients have a right to see the prices in advance of obtaining care, federal officials said. The invitation for comment, outlined in a passage of a broader patient-data proposal released last month, is a step toward a possible rule that could require providers to release such information.

The administration's vision—which would possibly include fines for noncompliance—is to arm patients with information needed to make healthcare decisions, much like shopping for other consumer services. Rates potentially could be posted on public websites, where consumers would check the negotiated price of a service before they pick a provider, which could lead to lower copays or deductibles.


The U.S. Centers for Medicare and Medicaid Services (CMS) has issued a request for information for eliminating barriers and enhancing insurers' ability to sell individual insurance coverage from state to state. Specifically, CMS wants feedback on how states could use Section 1333 of the Affordable Care Act, which allows insurers to enter into a "healthcare choice compact" to sell out-of-state coverage if state regulators agree, and whether other mechanisms beyond Section 1333 would help insurers sell across state lines. However, questions surround the ability of out-of-state insurers to negotiate and establish provider networks in a new areas and which state would regulate the insurer.


The Office of the National Coordinator for Health Information Technology (ONC) continued to deploy the 21^st Century Cures Act by releasing its proposed regulation to advance interoperability, support the access, exchange and use of electronic health information and address information blocking events. ONC is also implementing Conditions and Maintenance of Certification requirements for health information technology (IT) developers and is supporting patient access to their electronic health information. The proposed rule would add further modifications to the 2015 Edition health IT certification criteria and ONC Health IT Certification Program to advance interoperability, improve health IT certification and lower burden and costs. The goal of the proposal is to guarantee coordination with the U.S. Centers for Medicare and Medicaid Services' proposed rule to advance interoperability and to enable greater patient engagement with and governance over their healthcare data.

Medicine, Drugs and Devices

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A clinical feasibility study of five individuals with cerebral palsy (CP) used instrumented gait analysis to measure how powered plantar-flexor assistance affected gait mechanics following multivisit acclimation. Compared to how each participant walked normally, walking with untethered exoskeleton assistance led to improved ankle plantar-flexion and knee extension, and residual flexion deformity across the lower extremity improved by a clinically significant 14.4 degrees.

Powered plantar-flexor assistance also raised average total positive ankle power by 44 percent, resulting in a 30 percent reduction in average negative biological ankle power and a 29 percent reduction in average positive hip power. The implication is that powered ankle assistance augmented, rather than replaced, biological function to produce a more efficient gait pattern, which was corroborated by a 19 percent enhancement in metabolic cost of transport.


The U.S. Centers for Disease Control and Prevention (CDC) guidelines for the use of opioids against chronic pain are having an adverse effect on many individuals with long-term pain, according to healthcare experts. In a letter to the agency, more than 300 healthcare providers noted that CDC's recommendation of a daily numerical threshold for opioid use has resulted in some insurers refusing reimbursement, pharmacies putting up obstacles to obtaining the drugs and risks for physicians who want to prescribe more. "Taken in combination, these actions have led many healthcare providers to perceive a significant category of vulnerable patients as institutional and professional liabilities to be contained or eliminated, rather than as people needing care," they said. As a result, they said, some patients have experienced unnecessary pain, while others have turned to illegal drug use. The experts urged CDC to examine how the limit is affecting patients and to clarify the guidelines.


A study was conducted to assess machine-learning algorithms for accurately predicting short-term outcomes following open reduction and internal fixation (ORIF) for ankle fractures. Two machine-learning models were created to identify patient and hospital characteristics associated with three outcomes and were evaluated using confusion matrices and receiver operating characteristic area under the curve values. A total of 16,501 cases were analyzed to assess morbidity and mortality and length of stay more than three days, and 33,504 cases were assessed at 30-day readmission. Older age, Medicaid, Medicare, deficiency anemia, congestive heart failure, chronic lung disease, diabetes, hypertension and renal failure were factors associated with a statistically significant increased risk of developing all three adverse events.

Logistic regression and gradient boosting exhibited similar area under the curve values for each outcome, but gradient boosting was more precise and more specific for predicting each outcome. The outcomes suggest multiple comorbidities may be associated with adverse short-term outcomes after ORIF of ankle fractures, and machine learning can accurately predict these outcomes.