News From ACFAS

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Considering a fellowship post-residency and have some questions? Mark your calendar for the College’s new, pilot program, ACFAS Fellowship Zoom Rooms.

This new program is a series of Zoom Meetings where specific programs gather online for short presentations of their programs, to meet prospective future fellows and to answer any burning questions that you have. There are three Zoom Rooms coming up on Tuesday, April 19; Tuesday, April 26; and Thursday, April 28. All Zoom Rooms will occur at 7:30pm CT.

Interested in learning more? Visit acfas.org/fellowshipzoomrooms for the full schedule and listing of participating programs in each Zoom Room and to register. ACFAS is heading to the City of Angels! Mark your calendars for the 2023 Annual Scientific Conference, February 9-12 in Los Angeles.

Join us for another opportunity to network with your friends and colleagues while enhancing your knowledge and skills with four days of cutting-edge sessions, hands-on workshops. Here are some important dates to also note for ACFAS 2023:

• Manuscript submissions due August 3, 2022
• Poster submissions due September 7, 2022

Registration opens in August! Keep an eye out on acfas.org for more information on the 2023 meeting.

Foot and Ankle Surgery

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A study sought to compare early weight bearing and functional outcomes and complications in patients undergoing certain rehabilitation strategies following open reduction and internal fixation (ORIF) for unstable ankle fractures (AF). A total of 1,421 patients with AF underwent ORIF at 11 institutions between April 2014 and March 2019, divided into Group E, which initiated weight bearing within six weeks post-surgery, and group L, which did so for more than six weeks afterwards. The mean duration of non-weight bearing and cast immobilization was shorter in group E, and no differences in American Orthopaedic Foot and Ankle Society score were noted. Rates of deep infection and reoperation in Group E were significantly lower compared to Group L, and no significant differences in superficial infection, nonunion, blistering, neurapraxia and wound dehiscence were observed. The authors recommend early postoperative weight bearing in patients with a surgically treated AF.


A study was held to compare jigless knotless internal brace surgery (JKIB) with other minimal invasive surgery (MIS) methods to repair acute Achilles tendon rupture, using 50 fresh porcine Achilles tendons. The goal was to model a progressive rehabilitation protocol where 20100 N was applied in the first 250 cycles, followed by 20-190 N in the second 250 cycles and 20-369 N in the third 250 cycles. The JKIB group had significantly higher survived cycles than the open, Percutaneous Achilles Repair System (PARS) and Achillon Achilles Tendon Suture System (ACH) as determined by post hoc analysis, while no significant difference in comparison with the Speedbridge (SB) was observed. In cyclic displacement after 250 cyclic loadings, the JKIB group exhibited no significant difference versus PARS, SB and ACH groups and significant less displacement than the open group. The implication is that JKIB could be an option for acute Achilles tendon repair in the MIS fashion in view of larger cyclic elongation compared with other MIS procedures.


The influence of varus-tilted distal tibial deformity on ankle instability following arthroscopic lateral ankle ligament repair (ALLR) for chronic lateral ankle instability (CLAI) was investigated. Fifty-seven ankles from 57 patients who received ALLR for CLAI were retrospectively analyzed, with tibial articular surface (TAS) angles measured on preoperative plain radiograph. Recurrent ankle instability was noted in 10 ankles, and the TAS angles of patients with recurrent instability were substantially lower. The receiver operating characteristic curve analysis exposed a 86.2 degree cutoff value of TAS angle for recurrent instability. Patients were divide into low-TAS and high-TAS groups, and univariate and multivariate analysis showed low TAS to be an independent risk factor for recurrent ankle instability and greater postoperative talar tilt angles.

Practice Management

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Experts say many surgeons at teaching hospitals do not explicitly inform patients when trainees will be performing procedures, when in fact patients should be notified when surgeries overlap. "For the average hospital that does simultaneous surgery or the average doctor who does it, it's an efficient use of their time, so they really don't want to change it," said Society for Patient Centered Orthopedics President James Rickert. More and more, surgeons themselves are advising against this practice. They say they are following an ethical imperative to be completely transparent to patients, even in the presence of safety concerns. Available research suggests while surgeries tend to be slightly longer when trainees participate, they are, on the whole, equally successful; most researchers also concur that resident involvement has no significant bearing on surgical outcomes.


Medical practices have multiple funding and loan options to choose from, with six proving particularly popular. Small business administration loans are perfect for business owners with outstanding credit pursuing a long-term loan and many physicians prefer them because they typically offer the lowest rates, longest terms and largest loan amounts. Bank loans align well with startups seeking customized funding that considers novel circumstances like student debt and larger practices with strong financial histories and a clear plan for how they will use their funding. Merchant cash advances offer more flexible lending requirements and a simpler application process than more traditional funding, with approvals based on the practice's overall health.

Lines of credit are the most flexible option, as they can be tapped and repaid whenever needed. Practice acquisition loans are engineered specifically to purchase another practice, and there are lending programs designed especially for doctors, requiring collateral or a personal guarantee. Finally, equipment financing is ideal for practices with substantial or immediate equipment requirements, and a down payment may be required.


To ensure supply chain resilience in the post-pandemic era, medical practices should review current workplace dynamics, the rapid maturation of care delivery and how prepared their organization is to maintain growth. Three elements every healthcare organization should address include maturing prime vendor relationships, critical stock management and solving inefficiencies in current processes. Areas worth considering include ongoing review of the Just-In-Time model, stockroom and par count modernization and variation in preference cards. Resilient supply chain tactics reflect industry trends and patient demographics, and clear goals are needed to inform the practice's supply chain vision. Plans should recognize strategic goals and include assessing systems and processes, then identify top priorities for the next 18 to 36 months according to relevant metrics. Priority areas will include places where work is heavily manual or paper-based and anywhere managers and staff can be enhanced by modernized technology.

Health Policy and Reimbursement

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Staffing shortages at state Medicaid agencies across the nation could hardly come at a worse time, with long waits and the looming expiration of the COVID-19 public health emergency declaration threatening to seriously disrupt beneficiaries' lives. Personnel are needed to answer questions, process information verifying Medicaid enrollment renewal or see whether patients qualify for a different health coverage program before the benefits lapse and they lose insurance. Jennifer Wagner at the Center on Budget and Policy Priorities said Medicaid renewals, although less arduous than initial applications, often entail a months-long leaning curve for eligibility workers. Meanwhile, other social services may be held up because many workers also oversee applications for other programs. Consumer advocates who connect people to safety-net programs are concerned that an overwhelming workload could be insurmountable for staff.


US Centers for Disease Control and Prevention (CDC) Director Rochelle Walensky, MD, is preparing the agency for a comprehensive review that will lay the groundwork for modernization and other improvements. Heavy criticism was leveled at the agency for the way it has managed the country's COVID-19 response, including missteps on coronavirus testing, surveillance and mask policies. "The lessons from the COVID-19 pandemic, along with the feedback I have received inside and outside the agency over the past year, indicate that it is time to take a step back and strategically position CDC to support the future of public health," Walensky wrote in an email to CDC staff. The transformation will begin with an external review of CDC's core capabilities. Coupled with an internal effort to collect feedback and suggestions, the work will help inform the development of new systems and a new plan for how the agency should be structured.


The US Centers for Medicare and Medicaid Services (CMS) has finalized an 8.5 percent increase in rates to Medicare Part D and Medicare Advantage (MA) plans, above the previously proposed 7.98 percent. The hike partly stems from the application of the rebasing/re-pricing impact, which was unavailable when the advance notice was released in February. The planned coding pattern adjustment of 5.9 percent remains unchanged, while CMS admitted to receiving comments requesting a higher adjustment than the minimum and that it must weigh differences in coding patterns across MA plans. "CMS continually reviews MA coding patterns and continues to assess how we calculate the MA coding pattern adjustment, how best to apply it and what the appropriate level of the adjustment should be," the agency stated in a fact sheet. CMS also invited feedback on what metrics it should follow to enhance health equity in MA and Part D star ratings, including comments on devising a health equity index to determine how MA and Part D plans performed in offsetting social risk factors and how it will impact star ratings.

Medicine, Drugs and Devices

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Recent studies suggest 30 percent to 40 percent of all US coronavirus deaths have been among diabetics, who are especially prone to severe illness from COVID. Diabetes impairs the immune system, while diabetics often struggle with high blood pressure, obesity and other underlying ailments that can exacerbate a coronavirus infection. Diabetes patients hospitalized with COVID spend more time in the intensive care unit, are more likely to be intubated and are less likely to live. "Millions of Americans were already struggling with diabetes, and then COVID came along and cut a huge swath of suffering and misery that has been largely overlooked by the public and policymakers," said David Kerr at Sansum Diabetes Research Institute. Diabetes, like COVID, has exacted a heavier toll on Latino and Black Americans, which New York University Langone Health's Nadia Islam said highlights systemic failures in health care delivery for low-income Americans.

Some studies also suggest a coronavirus infection can elevate the risk of developing type 2 diabetes, a disease that is largely preventable through nutrition and exercise. Doctors have also reported a sharp increase in young people being diagnosed with type 2 diabetes in the past two years, which many associate with the surge in childhood obesity during the pandemic. The crisis has in some ways benefited diabetes care by accelerating the adoption of technology, like telemedicine, that enables remote management of the disease. "The advances of recent years have been stunning but not everyone has access to them and that's just tragic," said Ruth S. Weinstock with the American Diabetes Association.


Patients have traditionally served as subjects in the medical research process, but they are now increasingly becoming collaborators for such diseases as long COVID-19. Diana Zicklin Berrent, founder of patient advocacy group Survivor Corps, says: "We bring experiential knowledge and have enough of an outsider's perspective to see inefficiencies that people enmeshed in the system can't see." Her group has been collaborating with researchers at Yale and other medical centers. Nabil Natafgi, an assistant professor in the department of health services policy at the University of South Carolina's Arnold School of Public Health, says the COVID-19 pandemic has compelled researchers to reassess how to optimally engage patients in research and make it more relevant for them. His colleagues recently enrolled 15 patient-experts as part of a virtual "patient engagement studio" to incorporate their experiences during the research. The federal government estimates that between 7.7 million and 23 million people may already have long COVID. Harlan Krumholz, a cardiologist at Yale, and his wife, Leslie, are using a for-profit platform they developed called Hugo Health to test the patient-first philosophy. The platform enables patients to link health-related data from electronic health records, their pharmacy and a smartwatch, while assuring users their data will not be shared unless they give permission. The first Hugo study in 2016 examined readmission and emergency department use following patients' discharge from the hospital. The platform is currently hosting a COVID-specific community, Kindred, where patients can answer polls and surveys as well as access expert information and peer support.


Medicare Part D beneficiaries who do not receive a low-income subsidy are required to pay a percentage of expensive drugs' price for each medication fill, which typically runs up to hundreds or thousands of dollars. Researchers calculated the proportion of Part D beneficiaries in fee-for-service Medicare, with and without a subsidy, who do not initiate treatment with high-price Part D drugs newly prescribed for four conditions. Analysis of 17,076 new prescriptions issued between 2012 and 2018 for Part D beneficiaries from eleven geographically diverse health systems determined that beneficiaries receiving subsidies were almost twice as likely to acquire the prescribed drug within 90 days as those lacking subsidies. Among beneficiaries without subsidies, noninitiation was observed for 30 percent of prescriptions written for anticancer drugs, 22 percent for hepatitis C treatment and over 50 percent for disease-modifying therapies for either immune system disorders or hypercholesterolemia. These results back legislative efforts to boost accessibility of high-price medications by reducing out-of-pocket expenses under Medicare Part D, especially for beneficiaries without low-income subsidies.