News From ACFAS

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Shake up your routine and catch up on the latest research in foot and ankle surgery—May’s Scientific Literature Reviews (SLRs) are now available!

No need to leave the house for new research—each month’s issue constitutes a state-of-the-art textbook chapter so you can stay ahead of the game with the newest summaries of published articles, studies, case reports, literature reviews and more. Topics you’ll find in May’s issue include the use of Smartphone Thermography, Tarsal Tunnel Decompression and Chronic Ankle Instability.

Visit acfas.org/SLR to see this month’s articles and all past issues. ACFAS Student Club Presidents fill an important role as the liaison between the College and their school. All nine of the podiatric medical schools have a club presence on campus and provide valuable ways for students to get involved and keep learning outside of the classroom. With the help of their officers, presidents coordinate club activities such as presentations and lectures, surgical skills and suturing labs, discussion forums, new student recruitment and more. The ACFAS Student Clubs are often the first interaction podiatry students have with the College and are instrumental in welcoming future foot and ankle surgeons into the profession.

Let’s wish the newest class of ACFAS student leaders success in growing the ACFAS community!

AZPod: Kayla Weber, Class of 2022
Barry: Karissa Badillo, Class of 2022
CSPM: Shane Hall, Class of 2022
DMU: Travis (Drew) Anderson, Class of 2022
Kent State: Hamidat Momoh, Class of 2022
NYCPM: Justin Erfanian-Taheri, Class of 2022
Scholl: Trevor Page, Class of 2023
Temple: Alexandra Brown, Class of 2022
Western U: Kevin Trinh, Class of 2023 Break up the monotony of your days with more e-learning opportunities from ACFAS! Join the conversation and hear discussions about trends in foot and ankle surgery and expert discussions on different schools of thought with ACFAS Podcasts.

Podcasts are released monthly on ACFAS OnDemand with new podcasts being released next month. Visit acfas.org/OnDemand to take your pick from the podcast library.

Foot and Ankle Surgery

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The study examined the role of microfracture (MFX) and concentrated bone marrow aspirate (CBMA) on the outcome of patients undergoing distraction arthroplasty (DA) for end-stage post-traumatic osteoarthritis (PTOA) of the ankle joint. A total of 78 patients who underwent DA for the treatment of end-stage PTOA from 2009 to 2014 were included in this study. Interventions were divided into four groups for comparison: DA+MFX (n = 8), DA+MFX+CBMA (n = 35), DA+CBMA (n = 22) and DA alone (n = 13). Patients undergoing DA+MFX or DA+MFX+CBMA had significantly worse motion when compared with DA alone. Patients undergoing MFX had significantly reduced postoperative joint space and a greater length of time to return to activity when compared to subgroups not using MFX. Moreover, the use of MFX was associated with significantly lower Foot and Ankle Outcome Scores.


The study investigated the epidemiologic characteristics of surgical site infection (SSI) following surgeries of ankle fractures. Among 1,532 patients who had undergone surgeries for ankle fractures in one hospital between January 2016 and 22019, 45 had a postoperative SSI, indicating an incidence rate of 2.9 percent. About 18 percent of SSIs were identified after discharge. Twenty percent of SSIs were caused by mixed bacteria, and 39 percent were caused by drug-resistant bacteria. In the final multivariate model, seven factors including five biomarkers were found to be independently associated with SSI: gender, perioperative blood transfusion, albumin <35 g/L, lower high-density lipoprotein cholesterol, elevated alanine aminotransferase and neutrophile/lymphocyte rate.


The study evaluated the effects of two-portal endoscopic surgery for osseous lesions causing posterior ankle impingement syndrome. Researchers conducted a retrospective case study analysis of all patients who underwent two-portal endoscopic surgery at a single institution between 2005 and 2016. Of the 52 patients, 49 were able to return to their previous sport/physical activity within a mean time of 5.8 months. At the completion of follow-up, the mean pain score during exercise had improved from 7.5 to 0.9 points. The mean work and sporting function scores improved from 5.9 to 9.6 points and 2.9 to 8.8 points, respectively. The mean score of the Short Form of the Revised Foot Function Index also improved by 77.7 points, from 84.4 to 6.7 at the completion of follow-up. There were no postoperative infections or any other major complications.

Practice Management

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Mastering patient access in the aftermath of COVID-19 will require a structured, data-driven approach. This includes analyzing the past 12 months of pre-COVID-19 patient volumes, which will help practice administrators staff appropriately for the future. Practices should also optimize provider schedules and offer patient-friendly tactics, ensuring that all hours are covered. Many groups instituted more defined triage processes during the pandemic, and this should continue moving forward. Moreover, preparing to handle patient backlog needs to be a top priority. Practices should consider any telehealth visits that have taken place in the interim that may need follow-up. Once a pre-COVID-19 patient volume is established, this should be treated as a minimum number of slots on which to base expanded schedules. Practices should prioritize which patients to contact first when clinics re-open, stratifying patients by diagnosis, risk or in order of first canceled visits.


As healthcare facilities prepare to resume elective surgery, they should be sure to engage patients and their families. Experts emphasize the importance of providing details about COVID-19 and following through on infection prevention measures. Specific strategies include the teach-back method, in which an individual communicating important information asks the patient to "teach back" what they have just said. Plain language is also important, with handouts written at a fifth-grade level to ensure effective communication. Practices could also benefit from multiple team huddles where important information is shared in order to minimize variation in guidance from staff.


According to a recent study in the Journal of the American Medical Informatics Association, patient portal implementation, patient electronic health record (EHR) access and data transparency help patients feel more engaged and empowered. EHRs have made it easier for patients to see and request changes to their medical records, meaning that there has also been a spike in such requests. Researchers said clinicians need to find a balance between ensuring record accuracy and encouraging patient engagement. Previous studies indicate the benefits of giving patients access to their data and the right to request record changes. One study of 6,225 patients, published in BMJ Quality and Safety, found that 44 percent of patients who were given a feedback tool looked at their notes, while 8 percent used the feedback tool. Of that 8 percent, 23 percent voiced concerns about their notes, and 57 percent of those responses were correct, resulting in a change.

Health Policy and Reimbursement

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Several of the biggest US for-profit insurers will give money back to customers and cut upfront costs for care and prescriptions after they got an unexpected windfall because patients delayed normal medical services during the pandemic. UnitedHealth Group Inc. said it will rebate premiums to some commercial customers and waive cost-sharing for Medicare members as part of a $1.5 billion pandemic assistance program. UnitedHealthcare said it would credit between 5 percent and 20 percent of a plan's premium cost for June for fully insured employer and individual health plans. Earlier, Humana Inc. announced it would waive cost-sharing for Medicare members to see primary care doctors for the rest of the year. While employees have lost their jobs and health insurance and medical care has been delayed to clear room for COVID-19 patients, insurers have seen a short-term increase in profits as medical procedures and visits were canceled. Meanwhile, Cigna's Express Scripts unit announced a new program for people who have lost health insurance as a result of COVID-19, called "Parachute Rx."


The American Hospital Association (AHA) and the American Nurses Association (ANA) have sent a letter to House and Senate leaders to provide more funding for hospitals under the Coronavirus Aid, Relief and Economic Security (CARES) Act. Originally, the law included $100 billion for the Public Health and Social Services Emergency Fund to cover provider expenses related to COVID-19. That money was used for expenses for personal protective equipment, increased surge capacity, increased staffing and lost revenue. The AHA and ANA says more funds are needed since all hospitals received $50 billion instead of $100 billion in CARES Act funding. The remaining $50 billion was used on COVID-19 hot spots, rural hospitals, Indian Health Service facilities and treating the uninsured. The two groups say money should be used for a variety of issues including survivor benefits for frontline nurses and physicians; education vouchers and student loan repayment; free regular testing of COVID-19 for healthcare workers and loan forgiveness for accelerated payments for hospitals.


State Medicaid programs may face cuts as enrollment surges. The federal government generally pays 60 percent of program costs, with poorer states receiving a higher share. Medicaid faces heightened demand as economic conditions worsen, leaving states facing more need at the same time that they have less money. Congress gave states a temporary 6 percent increase in the federal portion of Medicaid spending in an earlier coronavirus package, but state officials this increase will likely be washed out by an expected enrollment surge. The nation's governors say Congress must double the Medicaid funding boost to 12 percent as it did in the previous recession. The portion of state budgets devoted to Medicaid spending has grown quickly since the previous recession, making it a riper target for cuts. Medicaid spending on average accounted for 15.7 percent of state budgets in fiscal 2009, a number that jumped to 19.7 percent in fiscal 2019.

Medicine, Drugs and Devices

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Chilblains appear to be a symptom of COVID-19 infection. Federal health officials do not include toe lesions in the list of coronavirus symptoms, but some dermatologists are saying that so-called "COVID toe" should be sufficient grounds for testing. Several medical papers from Spain, Belgium and Italy described a surge in complaints about painful lesions on patients' toes, Achilles' heels and soles of the feet, but it was not always clear whether the patients were infected. Most cases have been reported in young people, and some experts say they may indicate a healthy immune response to the virus. The lesions appear to signal a mild or even asymptomatic infection and might develop weeks after the acute phase of an infection is over. Some of the people with the lesions have tested negative for the coronavirus, which may mean that these patients had an extremely mild version of the virus that was undetectable.

The toe cases make up half of all reports filed by skin doctors around the world to a new international registry started by the American Academy of Dermatology, which is tracking the complications. One hypothesis is that the lesions are caused by inflammation, a prominent feature of COVID-19, or by small micro-clots in the blood that could block the tiny vessels in the extremities, causing rashes on the toes.


The cybersecurity sector is coming to the rescue of hospitals, many of which are sustaining ransomware attacks. “This becomes a matter of life and death because hospitals have their IT systems locked down, sometimes medical devices, too and can't function,” explains André Pienaar, founder of C5 Capital, a cybersecurity-focused investment firm that launched the Cyber Alliance to Defend our Healthcare. About 20 firms so far have joined the coalition, which already has arranged to help 87 European hospitals through digital defense assistance provided at no cost by member companies and professionals. Organizers hope to reach similar deals with US companies this month. Efforts to help protect hospitals against cyber-bandits, whether they aim to hold networks hostage or steal valuable coronavirus research, are coming from other corners as well. The Cyber Threat Intelligence League, for example, is focused on identifying common security bugs that hospitals should patch and on removing the digital infrastructure that hackers are using to target healthcare systems.


Tests conducted recently by the National Institute for Occupational Safety and Health (NIOSH) indicate that roughly 60 percent of 67 different types of imported N95-style masks allowed entry of more particles than permitted under US standards. NIOSH used 10 samples from each of the 67 mask types in its tests. For one mask, the agency found it used unauthorized FDA logos and filtered out as little as 35 percent of particles. NIOSH's tests, along with recalls and testing by states, reveal that millions of defective masks were imported from China and other countries. NIOSH also found that the bulk of samples it tested had ear loops; all NIOSH-approved masks have headbands to ensure a secure fit to block liquid droplets. Under an emergency decision, FDA allowed the import and use of N95-style masks certified under foreign standards, including China's. Many of these foreign masks are allowed to use ear loops. Gregory Rutledge, an MIT professor, says his lab tested more than 40 masks in the Massachusetts stockpile that claimed to be made to China's KN95 standard. He found that just a third performed comparably to certified N95s, while approximately another quarter were pretty close.