News From ACFAS

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Take the lead in bringing the latest research to your peers and the profession. Submit your article to The Journal of Foot and Ankle Surgery (JFAS) and reach a targeted audience within the medical community that values your insights on improving patient care.

Published bimonthly and peer-reviewed, JFAS is considered the premier source for original, clinically focused articles on surgical and medical management of the foot and ankle. JFAS also offers you the option of publishing your work as an Open Access article to give your research maximum exposure.

When you write for JFAS, you not only blaze trails for future researchers, you set the course for the future of podiatric medicine. Visit the Author’s Corner on jfas.org to learn how to submit your article for consideration. ACFAS welcomes the new Student Club presidents for the 2017–2018 school year:

• AzPod: Kyle Schwickerath, Class of 2020
• Barry: Elizabeth Ansert, Class of 2019
• CSPM: Lance Hopkin, Class of 2019
• DMU: Zach Croy, Class of 2019
• Kent State: Britain Wetzel, Class of 2019
• NYCPM: Brent Blanck-Singer, Class of 2019
• Scholl: Michael Savisky, Class of 2020
• Temple: Anthony Samaan, Class of 2019
• Western U: Thomas Yates, Class of 2019

ACFAS Student Clubs are located on all nine podiatric medical school campuses and provide student club members access to ACFAS scholarships, Regional Division funding and onsite visits from members of the Board of Directors. The clubs regularly invite ACFAS members to speak on surgical techniques and help enhance students' academic curriculum. Officite, an ACFAS Benefit Partner, shares advice for responding to online reviews:

Positive Reviews: Short and Sweet Responses
Post succinct responses to positive online reviews. Thank the reviewer and say that his or her opinions are important to you.

Avoid flowery language and do not ask the reviewer to refer people to your practice.

Negative Reviews: Wait-and-See Approaches
Put negative reviews into perspective because people sometimes exaggerate their grievances when they feel ill or upset. And if your practice rarely receives negative feedback, most who skim your reviews will pay little attention to it.

If you know the reviewer's identity, you might call that person and ask him or her to come see you so you can both try to work out your differences.

If other patients post responses in which they counter the negative reviewer's claims and compliment your practice, you need not write something of your own.

Disputing Negative Reviews
Challenge an unfair review broadly. Address the substance of the criticism but not the person who made it.

If a patient has complained online that one of your staff members did not answer a question, explain that your office policy is to answer all questions fully and promptly and that you are proud of the service your employees provide.

For more on this topic, contact Officite at (855) 777-0548.

Foot and Ankle Surgery

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Patient-reported outcome measures (PROMs) are increasingly used to evaluate results in orthopedic surgery. To enhance good responsiveness with a PROM, the minimally important change (MIC) should be established. Researchers assessed MIC for the Self-Reported Foot and Ankle Score (SEFAS) used in Swedish national registries. Patients with forefoot disorders (n = 83) or hindfoot/ankle disorders (n = 80) completed the SEFAS before surgery and six months after surgery and also completed the patient global assessment (PGA) scale—as external criterion—at six months. MIC was calculated by median change scores in improved patients on the PGA scale and by the best cutoff point (BCP) and area under the curve (AUC) using analysis of receiver operating characteristic curves (ROCs). Researchers found the change in mean summary score was the same, nine (SD 9), in patients with forefoot disorders and in patients with hindfoot/ankle disorders. MIC for SEFAS in the total sample was five score points (IQR: 2–8) and the measurement error was 2.4. BCP was five and AUC was 0.8 (95 percent CI: 0.7–0.9). As shown in the team's previous studies, the SEFAS has good responsiveness. The score change in SEFAS six months after surgery should exceed five score points in both forefoot patients and hindfoot/ankle patients to be considered as being clinically relevant.


New research seeks to retrospectively measure the outcomes of foot-sparing surgery at one year follow-up for patients with diabetic foot ulcers. Researchers assessed wound healing involving surgical debridement, toe, ray and transmetatarsal amputations by reviewing the electronic files of patients attending the Wound Expert Clinic. A total of 129 cases in 121 patients were identified for inclusion. Researchers report that complete wound healing was reached in 52 percent (61/117) of the patients within 12 months, and the need for additional surgery or for major amputation was 56 percent (n=72/129) and 30 percent (n=39/129), respectively. The need for an additional procedure was particularly high after surgical debridement (75 percent, 33/44) and transmetatarsal amputation (64 percent, 7/11). Risk factors for nonhealing or for a major amputation were: infection (p=0.01), ischaemia (p=0.01), a history of peripheral arterial occlusive disease (p<0.01) and smoking (p=0.01). The study reveals some areas for improvement, including timely revascularization and performance of multiple debridement procedures if needed in order to save a limb.


As tendon transfer of the flexor hallucis longus (FHL) and the flexor digitorum longus (FDL) is an established procedure, exact knowledge of the formation of the chiasma plantare is of great interest. New research aims to reinvestigate the formation of the chiasma plantare and the composition of the long flexor tendons in order to clarify the inexact and partly contradictory descriptions published from 1865 onward. The chiasma plantare and the long flexor tendons in both feet of 50 formalin-fixed specimens of body donors (25 men and women) were analyzed by gross anatomical dissection. The researchers found the FHL involved in the first tendon in all cases, in the second one in 97 percent of cases and in the third tendon in about one half of cases (53 percent). In all instances, the FDL contributes to the third to fourth, in 98 percent the second and in at least 39 percent to the first tendon. The quadratus plantae (QP) reinforces the second to fourth tendon in nearly all cases, the fifth in about one half of cases and even the first tendon in 14 percent of cases. The FHL appears to be the better donor for tendon transfer to restore lost function, but harvesting the FDL seems to be more suitable to prevent long-term functional damage. The decision depends on the individual patient's needs and should be made with due care, according to the researchers.

Practice Management

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The Physicians Practice 2017 Staff Salary Survey determined just 35.5 percent of practices have a registered nurse on staff this year, compared to 45.4 percent last year. In addition, the poll found a decline in practices that had physician assistants, nurse practitioners and care coordinators on staff. Nevertheless, only 21.1 percent of practices reported cutting staff over the past year. Another key finding is that a staggering 87.2 percent of respondents said they will not add staff to comply with the Medicare and CHIP Reauthorization Act (MACRA), mainly because practices are planning on training current personnel for MACRA-related roles. The top staffing challenge for practices cited by respondents is a mounting workload and employees assuming dual responsibilities.


The U.S. Centers for Medicare and Medicaid Services has set up an online lookup tool so clinicians can determine whether they must participate in the Merit-Based Incentive Payment Program (MIPS) this year. The tool is on the Quality Payment Program, and qualifying clinicians can insert their national provider identifiers into the tool to ascertain their MIPS eligibility. Overall, clinicians are required to participate in the program if they bill Medicare Part B more than $30,000 a year and see more than 100 Medicare patients annually. Exempt are those who fall below this threshold, as well as clinicians who are new to Medicare or who participate in Advanced Alternative Payment Models and get a specified amount of revenue from those organizations or agreements. MIPS is a replacement for the Physician Quality Reporting System, the Value Modifier Program and the Medicare electronic health records Incentive Program for eligible clinicians. Clinicians who qualify to participate but decline to do so will experience a four percent decrease in their Medicare reimbursement rate in 2019. Clinicians who are eligible for MIPS can opt to submit performance data as individuals or as part of a group. If they participate in an accountable care organization (ACO), the ACO can send quality data to MIPS on their behalf.


Physicians should be aware of their online reputation and protect themselves against unfair comments. When faced with online criticism, physicians should first investigate the nature and extent of the negative content and determine whether the critic can be identified. Should the physician know who the critic is, s/he must decide whether to contact this person. If the physician opts to contact in a friendly manner, the general goals are to try to find a way to resolve the critic's complaint and to request the removal of the negative post. The decision to pursue a more aggressive response can lead to the physician's lawyer sending a cease and desist letter, a strategy that frequently makes going to court unnecessary. If the identity of the attacker cannot be established, the physician can contact the website on which the content is hosted. Federal law stipulates that websites are generally exempt from liability for decisions to leave, or to remove, content posted by their users. The site can therefore agree to remove content without fear of legal retribution. When physicians reach out to a website, they must understand the site's terms of use. Knowing the site's policies enables physicians to prepare a credible and persuasive explanation as to why the damaging content should be removed. Litigation is a tool of last resort, but if the defamatory nature of the negative content can be proven, a court order directing its removal will almost always be obeyed by a website.

Health Policy and Reimbursement

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According to a report by the U.S. Department of Health and Human Services inspector general’s office, 96 hospitals reported suspect data on dangerous infections to Medicare officials in 2013 and 2014, but the agency conducted no follow-up. The inspector general says Medicare should have completed an in-depth investigation of the hospitals that submitted those reports. The report recommended that Medicare “make better use of analytics to ensure the integrity of hospital-reported quality data.” The report was conducted following concerns that hospitals are "gaming" systems that allow them to receive a bonus or penalty based on reporting patient infection rates.


The U.S. Senate voted 57-42 to confirm Scott Gottlieb as commissioner of the U.S. Food and Drug Administration (FDA). Gottlieb previously served as deputy FDA commissioner under the George W. Bush administration. He has also served as an industry consultant, spoken at healthcare and investor conferences and written extensively about FDA. Gottlieb is known to favor free-market strategies as means to reduce drug costs. He is also skeptical of allowing Americans to import brand-name drugs from other countries, where they are often cheaper. Industry insiders believe Gottlieb will support a more lenient approach to drug testing and clinical trials.


Health insurers are requesting that state regulators sanction huge rate hikes for 2018 individual policies, partly because they as yet do not know if the Trump administration intends to help or hurt the Affordable Care Act's (ACA) health insurance exchanges. Insurers in Connecticut, Maryland, and Virginia, which have published requested rates, say their increases, which top 50 percent in some cases, may rise further if the federal government fails to assuage their concerns over ACA repeal-and-replace efforts by funding cost-sharing reduction subsidies and enforcing the mandate requiring most people to enroll in coverage. In addition, insurers expressed worry that the pool of individual plan members is growing sicker because fewer healthy members are enrolling. "There are warning signs here," says health consultant Joel Ario. "We still need some market stabilization. We are still not out of the woods."

Medicine, Drugs and Devices

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The Senate Committee on Health, Education, Labor and Pensions has introduced a bill that would require a company seeking "orphan drug" exclusivity for a medicine that treats a rare condition to show that the product is better than any older drug that treats the same condition. The proposal is part of the U.S. Food and Drug Administration Reauthorization Act of 2017.


Researchers have found that taking even over-the-counter doses of common painkillers can increase one's risk of heart attack. The likelihood of having a heart attack was calculated to increase by an average of 20 percent to 50 percent versus someone not ingesting nonsteroidal anti-inflammatory drugs (or NSAIDs). NSAIDs include everything from ibuprofen to naproxen to celecoxib, all of which are available over the counter and by prescription for higher doses to relieve pain. According to the researchers, the level of risk increased as early as one week into the use of any drug in this category and at any dose. Meanwhile, the risk associated with taking higher doses was greatest within the first month.


A study by researchers from Yale University has discovered that a third of all drugs approved for sale in the United States over a 10-year period were subject to postapproval "safety events." Out of 222 new drugs approved by the U.S. Food and Drug Administration between 2001 and 2010, 71 were the subject of later advisories. Further, the rate of these new safety issues after approval by regulators was twice as high among drugs that were granted accelerated approvals. The scientists noted "even with the most careful regulatory review and sensitive postmarket surveillance mechanisms, it may be impossible to detect other less-common events until several years after approval."