News From ACFAS

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The College is pleased to announce Naohiro Shibuya, DPM, MS, FACFAS as the new Editor-in-Chief of the Journal of Foot & Ankle Surgery (JFAS). Dr. Shibuya stepped into the editor role officially May 1 and will oversee the editorial content and management of the Journal taking over for the retiring D. Scot Malay, DPM, MSCE, FACFAS.

"I can't think of a better person to follow Dr. Malay than Dr. Shibuya,” said ACFAS President Michael Cornelison, DPM, FACFAS. “Hiro's experience in the realm of scientific investigation within the field of foot and ankle surgery is extensive, but moreover, his enthusiasm for elevating the quality of it is unparalleled. Dr. Shibuya’s track record for innovation through his participation in many aspects of the College, most recently as Chair of our Annual Scientific Committee, leave no doubt in my mind that his stewardship of the Journal of Foot & Ankle Surgery will take it to new levels of excellence,” he adds.

As Dr. Shibuya steps into the role, he hopes to encourage high-quality submissions by expanding resources for authors, editors and reviewers to improve submission efficiency and to re-establish policies and guides for authors. “I am grateful to the ACFAS Board of Directors and to Dr. Malay who built such a great foundation of excellence for the Journal and the profession over the last 15 years.” Read more about Dr. Shibuya’s new role in an upcoming issue of ACFAS Update. The Evolution of a Profession reviews the first 75 years of ACFAS, providing a detailed account of the College’s role in changing the profession from chiropody to podiatry to foot and ankle surgery. One of the resounding themes is the hard-fought battle that has – and continues – to be fought for recognition and parity with allopathic medicine. As a result of this hard-fought evolution, the conclusion of the book states that “today’s ACFAS is far better able to cooperate, compromise, and above all, listen.”

Over the years, the College has leaned into these attributes and listened to member feedback and insights on diversity, equity, and inclusion. Previous ACFAS Leaders and Boards of Directors made the commitment for ACFAS to embrace diversity to advance the effectiveness of the College and the practice of foot and ankle surgery. The College’s members represent all aspects of society, including but not limited to race, ethnicity, national origin, gender, age, physical ability, sexual orientation, religion, and family status. ACFAS strives to be an inclusive organization, which values the differences in its membership and recognizes that diversity adds value to the organization, its mission, and the quality of its programs and services. The ACFAS Board will continue this important dialogue during its strategic plan review this Summer-Fall.

As background, in 2020 under the leadership of Scott Nelson, DPM, FACFAS, the ACFAS Board convened the Diversity, Equity, and Inclusion Task Force to build upon the DEI efforts from previous ACFAS leaders. Led by Chandana Halaharvi, DPM, AACFAS, this group was charged to start the discussion regarding ways the College can improve its DEI efforts, how ACFAS can better understand the value of diversity and inclusion and be transparent regarding this awareness, and to identify steps for the College’s leadership, volunteers, and faculty to better represent the makeup of the organization’s membership. As Immediate Past President, Thanh Dinh, DPM, FACFAS wrote in her brilliantly crafted December 2021 President’s Perspective, Dancing Together, “the ACFAS Diversity, Equity, and Inclusion Task Force has provided a strategic framework and identified bold initiatives to support a culture of diversity and inclusion in our organization.”

While the Board and DEI Task Force will continue this work during its planning process, below are updates on several DEI initiatives that were identified by the Board, the DEI Task Force, and/or other committees:

Volunteer Leadership Diversity

• The Board launched the Leadership Development Task Force in 2021. Led by ACFAS Membership Committee Chair, Laura Sansosti, DPM, FACFAS, this team is charged with developing a leadership development program that engages and prepares emerging leaders and future volunteers, as well as providing an inclusive and equitable pathway to ACFAS volunteer opportunities. This included an extensive outreach to stakeholder groups such as Past Presidents, Residency Directors, Committee Chairs, and RPC Members to help guide and refine the program design, which is currently in development.

Speaker Diversity

• The 2022 Annual Scientific Conference Planning Committee developed a track featuring all-female surgeons for ACFAS 2022.
• The Leadership Development Task Force is exploring incorporating pathways that include public speaking/speaker training into the new program.

Workshops and Education on Diversity, Equity, and Inclusion

• In 2021, the ACFAS Board held a half-day retreat on diversity, equity and inclusion facilitated by two leading association DEI experts.
• The 2021 Post Graduate Affairs Committee developed a Diversity and Inclusion in Healthcare program for the 2021 Residency Directors Forum.

Collecting Member Data and Feedback

• The 2021 ACFAS membership survey was updated to include more member demographic data to better gain better insights into the membership makeup.

These are the next steps in a long journey. The College continues to uphold its commitment to the collective dialogue, education, and action-focused approach to embracing DEI to advance the practice of foot and ankle surgery.

From PJ Andrus, CAE, ACFAS Executive Director

Foot and Ankle Surgery

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A retrospective chart review at two large healthcare institutions was conducted to evaluate patients that underwent surgical management of pilon variant posterior malleolar fractures and determine clinical outcomes that included time to union, union rates, soft tissue complications, infection and time to weight bearing. In all, 68 patients (51 females, 17 males) were included with 51 direct (19 posterolateral, 31 posteromedial), six indirect and 11 no-fixation approaches identified. Time-to-union differed significantly between direct fixation, indirect fixation and no-fixation. A posteromedial approach correlated with significantly shorter time to union when compared to a posterolateral approach. Fixation (direct or indirect) related to significantly increased likelihood of union of the overall ankle fracture pattern versus no fixation of the posterior malleolar component. Patients receiving direct fixation had significantly lower incidence of neurovascular damage compared to patients who underwent indirect fixation or no-fixation. No significant difference was observed between groups in terms of tendon damage, infection rates and time to weight bearing. The authors conclude that surgical management and specifically direct approaches yield better results in the short-term follow-up.


A study probed the distribution of foot–ankle offset (FAO) in 125 patients (250 feet), positing that threshold FAO values in valgus or varus could be identified as signs of higher risk of associated pathologies. Subjects were undergoing bilateral weight-bearing computed tomography and were clinically assessed and pathologies classified based on anatomic location (valgus- or varus associated). Hindfoot alignment was measured using FAO on three-dimensional datasets and tibio-calcaneal angles (TCA) on two-dimensional Saltzman-El-Khoury views. Mean FAO was 1.65 percent ± 4.72 and mean TCA was 4.15 degrees ± 7.67. Clinically, 167 feet were normal, 33 varus and 50 valgus with FAO values of 1.71 percent ± 3.16, -4.96 percent ± 5.30 and 5.79 percent ± 3.77, respectively. Mean FAO was 0.99 percent ± 3.26 for non-pathological feet, -2.53 percent ± 5.05 for lateral and 6.81 percent ± 2.70 for medial pathologies. Threshold FAO values of -1.64 percent and 2.71 percent best anticipated the risk of lateral and medial pathology, respectively.


Study results indicate that a Cincinnati incision followed by tendon debridement and calcaneoplasty for revision surgery for insertional Achilles tendinopathy is safe and reliable, realizing clinically relevant improvement in the Victorian Institute of Sport Assessment Scale for Achilles Tendinopathy (VISA-A), the EQ5D questionnaire and the visual analog scale (VAS) at 24 months follow-up. The study yielded data from 33 patients with a mean age of 43.9 years old, of whom nine were female. The left side was involved in 19 patients, and no clinically relevant complications were reported in any patients. Most EQ5D subscales showed improvement at last follow-up, including Usual Activities, Mobility, Pain/Discomfort and Thermometer. Evidence did not indicate statistically significant change for the Self-Care and Anxiety-Depression subscales, and both the VISA-A and VAS scores improved significantly at last follow-up.

Practice Management

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There are four pitfalls to avoid when selling a medical practice, the first being not planning ahead of time or waiting too long to sell. Physicians who want to retire quickly and sell their practice within 12 months lag behind the power curve significantly, and suitors who see that the seller has been planning and considering this for some time are likely to pay more. The second error is not finding the right transactional consultant to help with succession planning. The third mistake is to set an unreasonably high price for the practice or a price that is too low. Pricing decisions should be based on the practice's specialty, similar practices, the current economy and the marketplace. The fourth and final mistake is selling to the wrong party, especially with little or no money down along with an extended contract.


Medical providers must collect payments owed as quickly as reasonably possible, ensure they are accurate and completely captured and keep collection costs to a minimum. This ability is complicated by the challenge of hiring and keeping staff amid burnout and labor shortages, empowering productivity for staff working remotely, new delivery models and the distribution of data across disparate systems. Providers can deploy digital tools that encourage patient engagement while boosting convenience and efficiency for patients and staff at various points throughout the patient journey. These include patient self-scheduling, automated omnichannel reminders, pre-arrival and in-clinic digital check-in, digital billing and bill reminders and flexible payment plans.


The pandemic has accelerated trends in physician practice consolidation and increased the number of employed physicians at health systems, hospitals and corporate entities, according to a new study commissioned by the Physicians Advocacy Institute and conducted by Avalere Health. There was a sharp increase in the number of physicians employed by hospitals and health systems after the start of the pandemic, rising from 290,200 in July 2020 to 341,200 in January 2022, the study found. There was also a sharp increase in the percentage of physicians employed by corporate entities during the three-year study period, from 15.3 percent in January 2019 to 21.8 percent in January 2022. There was an 86 percent increase in the percentage of corporate entity-owned physician practices during the three-year study period, from 14.6 percent to 27.2 percent. Most of this increase occurred after the start of the pandemic.

Health Policy and Reimbursement

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Beginning June 1, Massachusetts' Board of Registration in Medicine will require all doctors in the state to take two hours of implicit bias training, focusing on attitudes toward gender, race, ethnicity and culture. The goal is to help them overcome unconscious false convictions and prejudices. Most doctors are white, and research has repeatedly shown how their biases undermine healthcare for members of minority groups, even though the clinicians think they are doing their best for all patients. Scientists found doctors give non-white patients lower doses of pain medication, deliver poorer quality care for older Black men with prostate cancer and diagnose appendicitis more slowly in Black children than in white children, leading to higher incidences of burst appendixes. George Zachos, executive director of the Massachusetts board, said the state mandate was created because the board "recognizes, based on studies, the importance of eliminating biases that lead to health disparities."


A federal investigation concluded that tens of thousands of Americans enrolled in private Medicare Advantage plans are denied needed care that should be covered under the program each year. The inspector general's office of the US Health and Human Services Department determined that tens of millions of denials are issued annually for both authorization and reimbursements, and audits of private insurers uncovered evidence of "widespread and persistent problems related to inappropriate denials of services and payment." The office's 2019 review of 430 denials found repeated examples of denied medical services that coding experts and doctors determined were medically necessary and required coverage. In learning that 13 percent of the requests denied should have been covered under Medicare, the analysts estimated that up to 85,000 beneficiary requests for prior authorization of medical care were potentially improperly rebuffed in 2019.

Advantage plans also rejected legitimate claims, with roughly 18 percent of payments denied despite meeting Medicare coverage rules, amounting to approximately 1.5 million payments across 2019. Plans in some cases ignored prior authorizations or other documentation necessary to legitimize payment. The investigators called on Medicare officials to strengthen oversight of Advantage plans and provide consumers "with clear, easily accessible information about serious violations."


Colorado is trying to help patients find doctors who have common cultural backgrounds, language, experiences or sexual orientation by asking insurers offering certain health plans to collect such information from health professionals and enrollees. A new law requires payers to offer the "Colorado Option," a plan on the state-run Affordable Care Act marketplace; the state is mandating that those plans build out culturally responsive provider networks, with a diverse pool of practitioners who can meet the needs of a diverse population. The framework includes better coverage for services that tackle health disparities and also requires anti-bias training for providers, front-office staffers and health plan customer service representatives. Plans must also boost the number of community health centers in their networks, in addition to certified nurse-midwives, to help lower maternal mortality. However, some physicians, particularly LGBTQ doctors, worry their safety could be jeopardized because much of Colorado's citizenry are conservative-leaning.

Medicine, Drugs and Devices

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To examine how physicians and patients balance the risks and benefits associated with selecting a new prescription drug, the US Food and Drug Administration's (FDA) Office of Prescription Drug Promotion (OPDP) seeks to conduct a new study. OPDP will focus on type 2 diabetes and psoriasis, dividing 800 patients and 800 physicians who have or specialize in those diseases to compare the preferences of the two groups. Participants will be requested to make choices based on profiles of mock prescription drugs in a process that will take 20 minutes. The data from these choices will be used to "explore the trade-offs that consumers and physicians are willing to make to avoid or accept specific attribute levels," according to OPDP's Federal Register notice.


Spending on pharmaceuticals rose 12 percent nationwide in 2021 amid high use of COVID-19 vaccines and therapies, according to an analysis by IQVIA Institute for Human Data Science. Out-of-pocket costs paid by patients totaled $79 billion, a $4 billion increase from the prior year and on par with 2018's level. Overall, these costs were less than $20 per prescription, but about 1 percent of all prescriptions filled, or 64 million, cost patients $125. About 81 million prescriptions were not filled last year. Murray Aitken, the institute's senior vice president and executive director, says the overall use of health services has returned to levels before the COVID-19 pandemic, but has not yet offset the backlog in missed patient visits, screenings, diagnostics, elective procedures and new prescription starts, which IQVIA described as a "concerning gap in preventive and treatment services." IQVIA also forecasts that overall US spending could reach approximately $450 billion in 2026, after accounting for rebates and other discounts issued by manufacturers, compared with $407 billion in 2021. The projected growth reflects such factors as increased competition among drug companies, pressure from payers and increased use of biosimilar medicines.