News From ACFAS

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If you’re looking to participate online in ACFAS’ popular coding courses—Coding Fundamentals or Coding and Billing for the Foot and Ankle Surgeon—register today before registration closes on June 6.

Coding Fundamentals is available onDemand until June 7. Coding and Billing for the Foot and Ankle Surgeon live streams on June 9-10.

If you can’t make either course virtually, both courses are being offered in person August 25 for Coding Fundamentals and August 26-27 for Coding and Billing at Walt Disney World’s Dolphin Hotel in Orlando. Take one course or both courses in one convenient location. Bundle pricing is available.

For more information or to register, visit acfas.org/PracticeManagement. The education never ends at ACFAS and we have a new course coming in October! Mark your calendars for Comprehensive Surgical Management of Challenging Cases, October 15-16, 2022.

This interactive two-day course gives you ample hands-on lab time complete with case presentations, lectures and demos. With two main case presentations the rest of the course is divided into lectures and hands-on labs where attendees will learn how to perform procedures based off of these two challenging cases, including:

• First Metatarsal Cuneiform Fusion with Bone Graft & 1st MPJ Medial or Lateral Capsulotomy
• Weil Osteotomy
• Long oblique 5th metatarsal osteotomy
• Evans Calcaneal Osteotomy
• Navicular Cuneiform Fusion with and without bone graft
• Gastrocnemius Recession
• And many more!

Registration is opening soon so save the date and check back at acfas.org/skills for more information.

Foot and Ankle Surgery

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The increase in artificial turf in the 1970’s was thought to have contributed to increased incidence of Turf toe injury in National Football League (NFL) players. Researchers used online resources to identify NFL players who sustained a turf toe injury between the 2011-2014 seasons. The performance of each offensive skill player was analyzed separately by calculating their power rating over 6 seasons. Injured offensive skill players were then compared to a control group consisting of all running backs and wide receivers without a turf toe injury who competed in the 2012 season. Seventy-one turf toe injuries were identified. Twenty-nine occurred on grass, 29 on turf and the playing surface of 13 injuries could not be identified. The average power rating (PR) prior to injury was 105.7/season (7.3/game), 87.3 (6.9/game) for the season of injury and 115.5 (8.1/ game) for post-injury seasons. The PR was not significantly different after a turf toe injury compared to before injury or to uninjured control player.


Researchers explored the modified Lapidus procedure's effectiveness in correcting the distal metatarsal articular angle (DMAA) in moderate to severe hallux valgus surgery. A retrospective chart review of 85 patients (99 cases) who underwent hallux valgus reconstruction with a modified Lapidus procedure between April 26, 2018, and Nov. 19, 2020, found the average DMAA decreased from 17.72 ± 6.18 degrees preoperatively to 9.19 ± 5.19 degrees two weeks postoperatively and 9.79 ± 4.62 degrees at the final follow-up on radiologic assessment. The average hallux valgus angle fell from 31.34 ± 10.39 degrees preoperatively to 13.34 ± 6.16 degrees two weeks postoperatively and 15.05 ± 7.43 degrees at final follow-up. Finally, the intermetatarsal angle decreased from 14.99 ± 3.82 degrees preoperatively to 4.66 ± 2.59 degrees two weeks postoperatively and 6.62 ± 3.46 degrees at final follow-up. A 3.03 percent recurrence rate was observed.


Even though an increased interest in the use of European Foot and Ankle Society (EFAS) score has been observed, no data comparing it with radiological findings has been presented in the literature. Accordingly, researchers investigated how the postoperative integration of the autologous matrix-induced chondrogenesis (AMIC) membrane for osteochondral lesion of the talus using the Magnetic Resonance Observation of Cartilage Repair Tissue (MOCART) Score is related to the clinical satisfaction of the patients. Twenty-four patients were included at least one year postoperatively. They had all undergone an AMIC procedure of the talus. MRI findings using the MOCART Score were correlated to the EFAS Score at the same time point. The results showed no correlation between the MOCART Score and the EFAS Score (R = –0.08) or between the MOCART Score, the Foot and Function Index (R = 0.2) and the Manchester-Oxford Foot Questionnaire (R = 0.12). There was no correlation between components of the MOCART Score with the EFAS Score (R between –0.32 and 0.23).

Practice Management

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A strategic plan is essential to a medical practice and its future sustainability. A strategic plan can define clarity and intention around how the practice can run and expand, and it is a tool for assessing strengths to tap, challenges to surmount and opportunities to chase. A plan also can guide decision making around where resources should and should not be focused, while also uniting the staff around a common purpose. Moreover, the plan enables the practice to correct its course if certain strategies are not yielding desired outcomes and offers a method for regularly evaluating the practice's well-being. The strategic plan should answer questions concerning the practice's mission, vision, core values, strategic priorities, actions and metrics/targets.


Implementing a remote and virtual workforce model can improve the quality of care for patients, which works to the medical practice's advantage. Office staffers face a less onerous workload when front-desk assignments like in-office patient and telehealth appointment check-ins, messaging and appointment reviews can be handled remotely. This frees up in-office staff to prioritize the delivery of excellent patient care, while technological solutions can also support remote work by medical assistants. Physicians and providers have a host of remote and hybrid work solutions to choose from, including telehealth call prioritization, patient monitoring and answering of patient questions. Offices interested in investing in remote work should have an initial checklist, which may include patient arrival and initial check-in capabilities, digital check-in for all required tasks, telehealth availability, secure messaging, remote patient monitoring with alert functionality, device ordering and management systems, post-procedural care management and electronic health record integration.


Research has long indicated a lack of respect among doctors toward patients who are overweight or obese, and the Association of American Medical Colleges (AAMC) aims to address this with by launching new diversity, equity and inclusion standards in June. Scott Butsch at the Cleveland Clinic's Bariatric and Metabolic Institute says medical schools devote too little attention to obesity training, while doctors often approach it with a one-size-fits-all mentality. The AAMC has devised a professional readiness exam (PREview) for aspiring medical school students to evaluate cultural competence, social skills and listening skills, plus the ability to think through situations they may confront in medical school and clinical settings. The competency standards coming next month will address racism, implicit bias and gender equality, with the goal of teaching doctors how to talk with overweight patients.

Health Policy and Reimbursement

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US Vice President Kamala Harris and Surgeon General Vivek Murthy issued a warning about burnout among healthcare workers after more than two years of the pandemic, which if unaddressed could lead to severe shortages. The report warns of a projected shortfall of 3 million "essential low-wage health workers" in the next five years and almost 140,000 doctors by 2033. The Biden administration is urging new investments and processes to safeguard the mental well-being of healthcare staff, which includes expanding counseling offerings, reducing administrative burdens and encouraging worker safety on the job. Murthy said without such actions, the nation will be ill-equipped to deal with future public health emergencies, and "we will send a message to millions of healthcare workers that their suffering does not matter."


According to a study published in JAMA Network Open, insurer participation in the Affordable Care Act (ACA) marketplace may have adversely affected health equity in the early days of the marketplace in 2014. Researchers, who say further study may be warranted with new data, found that counties with higher non-Hispanic Black populations showed just over a 14 percent decline in insurer participation in ACA markets. The study says, "An important link between historical redlining and health outcomes is likely related to health insurers' strategic considerations about what markets to participate within, how to design coverage plans and what physicians to include within their networks based on neighborhood characteristics." Declines in participation also varied by provider specialty, with family medicine specialists falling the most.


A new study from Blue Cross Blue Shield Association and America's Health Insurance Plans suggests the No Surprises Act enabled commercially insured patients to avoid more than 2 million unexpected medical bills in January and February. Most of the law's stipulations became effective in early 2022. The study authors expect that more than 12 million potential surprise bills will be avoided this year if the trend continues.

Medicine, Drugs and Devices

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Researchers isolated mesenchymal stem cells (MSCs) from the synovium of ankle joints in patients with chronic lateral ankle instability (CLAI) to compare the characteristics of MSCs derived from the synovium anterior to the talus with those from the surrounding anterior talofibular ligament (ATFL) synovium. Synovium was harvested from 14 patients who underwent arthroscopic ATFL repair for CLAI without osteochondral lesions of the talus (OLTs). Synovial fluid was also harvested. MSCs were isolated from both types of synovial tissue, as well as synovial fluid. The number of MSCs in the synovium and their viability, proliferation, colony-forming units and potential to differentiate into adipose, bone and cartilage tissues were determined and compared between groups. Additionally, real-time polymerase chain reaction was used to assess the differentiation capacity of adipose, bone and cartilage tissues from both samples. No significant differences were observed in the sample weight (P = .051), number of nucleated cells per milligram (P = .272), number of colonies (P = .722),and yield obtained (P = .099) between the two groups. MSCs could not be isolated from synovial fluid. The frequency of oil red O–positive adipogenic colonies (P = .028) and the expression of the adipsin gene (P < .05) were significantly increased in the cells from the synovium anterior to the talus compared to those in the cells from the surrounding ATFL synovium. However, chondrogenic and osteogenic potentials were not significantly different between the two groups. The researchers concluded that synovial MSCs obtained from the ankle joint had self-renewal and multilineage differentiation potential, although the adipogenesis potential of MSCs from the synovium anterior to the talus was superior to that from the surrounding ATFL synovium.


A study in JAMA Health Forum found that drugs regarded as blockbusters and those approved under the US Food and Drug Administration's (FDA) accelerated approval pathway were more likely to receive a new formulation. Ravi Gupta, MD, of the National Clinician Scholars Program at the University of Pennsylvania in Philadelphia, and colleagues examined the rate of reformulation for 206 approved novel tablet and capsule drugs in the Drugs@FDA database between 1995 and 2010. They looked at such factors as the drugs' sales status, whether they were approved under the accelerated approval pathway and whether they were on the World Health Organization's list of essential medicines. Drugs with blockbuster status were much more prone to having a new formulation compared with drugs that did not achieve blockbuster status. Drugs that received accelerated approval were also significantly more likely to receive a new FDA-approved formulation compared with drugs not approved under the accelerated approval pathway. New formulations were significantly less likely among orphan drugs compared with non-orphan drugs, the researchers found. They observed, "Taken together, these results suggest that revenue is a substantial driver of whether and when a manufacturer secures FDA approval of the first new formulation of existing drugs, reinforcing concerns that manufacturers are using evergreening strategies to maintain revenue and avoid generic competition." The authors concluded that policymakers "should consider the role of new formulations more carefully to incentivize therapeutically valuable innovation and minimize strategies to avoid generic competition."