News From ACFAS

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Winning manuscripts will receive the following prize amounts:

First Place: $3,000
Second Place: $2,500
Third Place: $1,500
Honorable Mention: $750

Is your original research study a winner? Find out by entering the College’s annual manuscript competition, set for February 19–22, 2020 at the Annual Scientific Conference in San Antonio.

Your manuscript must be in scientific format and must fall under one of the following categories:

• Arthroscopy
• Biomechanics and Anatomy
• Diabetic Foot
• Forefoot Reconstruction
• Heel Pain
• Orthotics/Prosthetics/Pedorthics
• Peripheral Nerve Disorders
• Physical Therapy/Rehabilitation
• Rearfoot and Ankle Reconstruction
• Trauma (Surgical/Conservative)
• Wound Care/Infectious Diseases

Entries for the 2020 competition are due August 15, 2019. Check acfas.org during the summer for submission guidelines and criteria. Listen up! A just-released podcast on ankle fractures is available now in the ACFAS e-Learning Portal.

Hear your colleagues discuss how they manage ankle fractures from the moment they see the injury in the ER to when they treat it in the OR. Gain firsthand insights on splinting, scoping, syndesmosis repair and fixation, and learn what actions you can take early on to achieve the best patient outcomes.

Access this podcast at acfas.org/e-learning, and visit the e-Learning Portal often for more ways to earn CME on the go. Thinking about submitting an original research article to The Journal of Foot & Ankle Surgery (JFAS)? Here are five great reasons why you should publish your work:

1. Be the voice of your profession.
Your peers and the medical community count on you for the latest updates on foot and ankle surgery and methods to improve patient care.

2. Inspire new research.
Your discoveries could lead to new ideas and advancements that keep the profession moving forward.

3. Contribute to evidence-based medicine.
Enhance the current literature with facts and hard data.

4. Reach a global audience.
Publish your study as an Open Access article and give readers worldwide full access to your work.

5. Connect with other researchers.
Establish new contacts and collaborate with those who share your research interests.

To submit your manuscript now through the new JFAS Editorial Manager^®, visit jfas.org.

Foot and Ankle Surgery

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Researchers evaluated a full-thickness skin graft as a one-stage method of secondary debulking to achieve both aesthetic and functional results following flap reconstruction of the ankle. The method was conducted on 22 patients who had undergone reconstruction with flaps for ankle defects from January 2004 to June 2016. Nineteen cases were free myocutaneous flaps, two were free fasciocutaneous flaps and one was a distally based sural artery flap. In the operative procedure, the full-thickness skin was harvested from the flap and regrafted on the defatted fascia with tie-over dressing.

The general average follow-up time was 12 months. All the grafted skins took well following debulking, and patients could wear their own shoes without difficulty and regained ease of ambulation. The reconstructed area decreased to an average of 28.92 percent, versus predebulking area; the reconstructed ankles realized good symmetry with respect to the contralateral side.


Interposition arthroplasty of the first metatarsophalangeal (MTP) joint has recently experienced renewed interest as a treatment for hallux rigidus. Researchers sought to systematically review the rapidly expanding literature on PRO following interposition arthroplasty of the first MTP joint. A total of 20 studies were included in the review, comprising 498 patients and 539 feet with mean time to follow-up of 4.5 years. The most common substance used for interposition in the included studies was autogenous first MTPJ capsular tissue, a technique reported on in 12 (60.0 percent) of the included articles. In studies reporting preoperative and postoperative outcomes by way of a standardized outcome scoring system, mean group improvements exceed minimal clinically important differences in the majority of studies. Eighty-five percent of the studies included in this review were of Level IV quality evidence, and of this subset of studies, 70.6 percent were of a retrospective nature. Progression to further surgery was observed in 3.8 percent of toes. The most common complication reported was transfer metatarsalgia of one or more lesser toes, which was observed in up to 57.9 percent of patients in one study. Interposition arthroplasty appears to be a viable option for the treatment of moderate to severe hallux rigidus in patients looking to salvage motion through the first metatarsophalangeal joint. A wide array of autogenous, allogeneic and synthetic implant materials have surfaced in recent years, but long-term follow-up and prospective, comparative study designs with low risk of bias are limited, the researchers conclude.


Subtalar joint distraction arthrodesis has been recommended for the treatment of conditions such as nonunion or malunion of subtalar joint arthrodesis due to post-traumatic arthritis. Deformities created in the frontal and sagittal planes of both these conditions are complex, making the conditions difficult to treat. If these malalignments are not addressed, ankle joint instability and wear occur over time. Generally, either autograft or allograft bone has been used to perform distraction arthrodesis of the subtalar joint. Although studies have shown successful use, there have been complications. Autografts have resulted in donor site morbidity and limitations on graft size, and allografts have shown high nonunion rates. Both autografts and allografts have shown graft collapse over time. Recent literature has discussed the use of titanium technology to span large defects in bone healing. Studies have shown that titanium provides superior strength and bone incorporation compared with autografts and allografts. Researchers presented a case series comprising two cases in which titanium truss technology was used for distraction arthrodesis. Although this series was limited in patient numbers, both cases demonstrated effective graft incorporation with no loss in height over time and earlier return to activity compared with previous studies that used autograft and allograft wedges.

Practice Management

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Physicians must talk to someone if they are unsatisfied with their job and not delay this conversation. Persons worth talking to include immediate colleagues, to gain perspective, solutions and immediate advice. One's supervisor, like the physician chief of the group, is also recommended, while administrators can be supportive in certain institutions. They can include chief medical officers or CEOs.

Physicians also can tap colleagues in other places and parts of the country for advice. Family can be an important lifeline as well, especially when they notice their loved one's unhappiness and frustration.


About 30 percent of a medical practice's revenue stream comes from deductibles, copays and coinsurance, says Elizabeth Woodcock, president of Woodcock and Associates. As a result, it is important for practice managers to notify patients of policies early. Industry experts say these talks should begin even before a patient enters the office. For example, phone calls before an appointment about a copay that will be due opens the door for conversation about payments. This discussion can be continued once a patient has arrived for their appointment. This is also a good time to share printed documents that explain payment policies, answer billing questions and request insurance information.


A survey by American Well reveals that about 20 percent of physicians currently use telehealth to care for patients, up from about 5 percent in 2015. Sixty-one percent of physicians who are not currently using telehealth indicated they are either very likely or likely to start using telehealth by 2022, representing half a million doctors, according to the survey. Among physicians adopting telehealth visits, 93 percent said it enhances patients' access to care, 77 percent said it contributes to more efficient use of time for doctors and patients, and 71 percent said it helps to reduce health care costs.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) wants state Medicaid agencies to examine ways of integrating care for patients eligible for both Medicare and Medicaid. In a letter to state Medicaid directors, CMS Administrator Seema Verma cited three approaches states could take to merge care for dual-eligible patients, with a target of enhancing the quality of their care and curbing costs. The letter said CMS would consider allowing more states to participate in a demonstration testing a capitated model, in which nine states are currently taking part. The agency is also willing to grant long-term extensions to participating states or allow them to expand the demonstration to new geographies. Under these demonstrations, states, CMS and Medicare-Medicaid plans enter into three-way contracts to provide a full menu of services to dual-eligible patients.


The Trump administration will launch a new program that offers new ways to pay primary-care doctors, including flat monthly payments to physicians and higher payments for medical practices specializing in the chronically ill, as a way to lower the costs of Medicare's usual fee-for-service system. U.S. Centers for Medicare and Medicaid Services Administrator Seema Verma says the flat-fee method and other payment alternatives could be a path for the Medicare payment system to achieve better outcomes for patients. The program is voluntary, but the administration hopes that nearly 25 percent of all primary-care doctors will participate, says U.S. Health and Human Services Secretary Alex Azar. The administration hopes that as many as 11 million Medicare beneficiaries also will be involved. Azar says medical practices will be paid a bonus if the patient stays healthy. If not, the doctors will share some of the risk.


Medicare's Hospital Insurance (HI) Trust Fund, which funds Medicare Part A, will be able to pay full benefits until 2026, the same as last year's report, according to the Medicare Board of Trustees. In their annual report, the board said that for the 75-year projection period, the HI actuarial deficit has grown to 0.91 percent of taxable payroll from 0.82 percent in the 2018 report. Total Medicare costs, including both HI and Supplemental Medical Insurance (SMI), is expected to reach 5.9 percent of gross domestic product (GDP) by 2038, up from about 3.7 percent of GDP last year, rising gradually to about 6.5 percent of GDP by 2093. The SMI Trust Fund, which funds Medicare Part B and D, had $104 billion in assets at year-end 2018. Costs associated with SMI are expected to increase from 2.1 percent of GDP in 2018 to about 3.7 percent of GDP in 2038. Additionally, Part D drug spending projections are lower than in the 2018 report due to slower price growth and a trend of increasing manufacturer rebates.


A new report from the U.S. Congressional Budget Office (CBO) reveals that more than 1 million Americans have lost health insurance coverage since 2016. CBO estimates that the number of Americans without insurance jumped from 27.5 million in 2016 to 28.9 million in 2018. The report is the latest to show that the number of uninsured people has been on the rise since President Donald Trump took office. According to CBO, the number of people who purchase coverage on the individual market outside of the federal and state-run exchanges fell to 4.9 million in 2018 from 7.4 million in 2016, and the number of people who purchased unsubsidized insurance through the exchanges dropped to 1.3 million from 1.6 million over the same period. In both cases, the declines are attributed to rising premiums. At the same time, the number of people with employer-sponsored coverage has increased.

Medicine, Drugs and Devices

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A report from the Center for Regulatory Effectiveness (CRE) suggests that the 340B drug discount program may affect patient access to costly drugs. CRE found that the number of uninsured, impoverished patients without access to medical care and dental care grew between 2009 and 2015, even as the overall number of 340B hospitals more than tripled. According to the review, 340B qualifying patients were prescribed more medication and costlier drugs than patients being cared for by non-340B providers. The report also discovered that 340B hospitals charge at least twice as much for outpatient oncology care as non-340B providers.


A study published in the European Heart Journal indicates that using antibiotics for two months or longer may be linked to an increase in a woman's risk for cardiovascular disease (CVD). The finding applied to women who used the drugs when they were age 40 years or older. Researchers used data on 36,429 women free of CVD at the start of the study who were participating in a continuing long-term health study. The study controlled for such factors as family history of heart attack, body mass index, hypertension and use of other medications.