News From ACFAS

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New residents, take your career to the next level with ACFAS! PGY-1 resident membership is free through September 30, 2023, so you have a chance to join the ACFAS ranks at no cost to you.

As an ACFAS resident member, you’ll have access to:

• Discounted registration for ACFAS 2023, February 9-12 in Los Angeles
• 70+ hours of recorded clinical sessions in ACFAS OnDemand
• 15+ in-person CME opportunities offered annually
• A listing of over 54 fellowship programs with ACFAS status—including program contacts, details and application information
• Virtual ACFAS Journal Clubs held each month
• Monthly Scientific Literature Reviews
• A growing podcast library featuring surgical and non-clinical occupation-related topics

Join ACFAS and benefit first-hand from the College’s mission of empowering our members to be proven leaders and lifelong learners who positively impact the lives of their patients. The newest two-part podcast Functional Expectations and Limitations after 1st MPJ Fusions is now available on ACFAS OnDemand.

Join moderator Ron G. Ray, DPM, FACFAS and panelists Paul D. Dayton, DPM, MS, FACFAS, Michael D. Dujela, DPM, FACFAS and Brett D. Sachs, DPM, FACFAS for an interesting conversation on setting patient expectations for 1st MPJ fusion procedures.

Check out this and other podcasts now at acfas.org/OnDemand.

Foot and Ankle Surgery

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A retrospective monocentric study probed the clinical effectiveness of percutaneous reduction and screw fixation without bone grafting in Sanders Type-II and Type-III displaced intra-articular calcaneal fractures (DIACFs). Included were 38 patients with Sanders Type-II and Type-III DIACFs, including 30 males and eight females aged 21 to 61. The Essex-Lopresti framework classified 27 fractures as the tongue type and 11 as the joint compression type; the Sanders classification described 27 fractures as type II and 11 as type III. Postoperatively, the calcaneal height had recovered to 39.8 ± 2.1 millimeters, while the Böhler angle had recovered from 4.2 degrees ± 13.6 degrees preoperatively to 27.2 degrees ± 3.4 degrees. Healing was observed in all fractures, and no differences were noted in outcome measures six months after surgery or at final follow-up compared to the immediate postoperative values. At final follow-up, the American Orthopaedic Foot and Ankle Society hindfoot score was 91.7 ± 7.4 points, with an excellent and good rate of 92.1 percent. The Maryland Foot Score was 90.3 ± 7.8 points, with an excellent and good rate of 92.1 percent. The visual analog scale score was 2.2 ± 1.5 points.


Research detailed the use of bipedicle conjoined flap on the lower abdomen and groin site in covering the exposed ankle and foot. Between May 2018 to September 2020, 36 patients (27 males and nine females) with a mean age of 32 years underwent the one-stage coverage of ankle and foot defects with the bipedicle conjoined flap. Thirty-six flaps survived completely without major complications and one flap exhibited mild venous congestion. The average flap size was 35 × 15 centimeters squared and all flaps were available for a mean follow-up of 18 months. Natural shape and walking function were realized with restored protective sensation.


A study was conducted to present the dual-perforator flap with wide pedicle (DPFWP) and compare it with the sural neurovascular flap with peroneal artery perforator (SNFPAP) in foot and ankle reconstruction. Different surgical methods dictated that 82 patients were split into a 42-case DPFWP group and a 40-case SNFPAP group. All cases received a flap surgery following radical debridement. Both groups exhibited homogeneous age, sex, body mass index, etiology, location and follow-up duration. The DPFWP group had larger flap length and flap width than the SNFPAP cohort. The DPFWP group also had a lower complication rate and better cosmetic and functional outcomes than the SNFPAP group in postoperative follow-up.

Practice Management

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A medical practice's social media marketing plan should follow a similar developmental approach to that of an individualized care plan and follow best prescribed guidelines. Five standard actions are viewed as key elements for developing the foundation of a successful social media plan, staring with a willingness to listen. Activism is the second recommended action, as frequent and regular activity will enable the practice's social media content and posts to reach their full potential. The third step is to plan for routine follow-ups by devising and assessing key performance indicators, while the fourth action involves keeping up to date on the latest breakthroughs. The fifth and final step is to connect with the social media audience on a person-to-person basis, which engenders trust and engagement.


Research was conducted to evaluate patterns in actions against physician licenses resulting from substance use and psychological health compared to physical health. The authors assessed all physicians with actions against their licenses between 2004 and 2020 reported in the National Practitioner Databank. All in all, 5,032 actions were related to substance use, psychological impairment or physical impairment. Actions concerning substance use decreased in frequency between 2004 and 2020 from 5.6 to 1.6 actions per 10,000 physicians. Actions related to psychological impairment slightly declined during that same period from 0.8 to 0.2 actions per 10,000 physicians. Frequency of actions related to physical impairment also saw a moderate drop from 0.7 to 0.2 actions per 10,000 physicians.

Compared with those with physical impairment-related license actions, an indefinite rather than permanent penalty length was more likely to be imposed on physicians with license actions related to substance use or psychological impairment. They were also more likely to have an emergency action enforced against their license and to have a greater mean number of lifetime license actions.


Caravan Health's Fred Wallisch writes that physician burnout has reached "epidemic proportions," which can adversely affect the quality of patient care. "With burnout at all levels of healthcare, we run the risk of taking a step backward in our move toward value," he warns. Remedying this requires a three-pronged solution that emphasizes the system, the practice and the individual. System-level actions include discussing and proactively addressing burnout with the C-suite and improving the culture to guarantee providers' concerns are aired. "At the practice level, team-based care initiatives can significantly reduce the burden placed on physicians," Wallisch notes. Finally, individual-level efforts can involve removing the stigma associated with burnout, establishing peer support groups and encouraging individuals to engage in counseling and therapy.

Health Policy and Reimbursement

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Evidence is growing that medical debt is increasingly burdensome for Americans, with a Kaiser Health News and NPR investigation showing that 41 percent of adults, or over 100 million people, face large medical debts. Much of this debt is carried on credit cards, loans from family members, or through payment plans with medical providers or hospitals. A recent Kaiser Family Foundation poll found that 25 percent of adults surveyed had medical debt of over $5,000, and about 20 percent said they will not be able to repay it. These debts are preventing some Americans from saving for retirement and affording food and other essentials and are pushing some toward bankruptcy. Meanwhile, about 14 percent of those with debt said they have been denied access to medical care due to unpaid bills.


New research found diabetic patients who participate in a free Annual Wellness Visit covered by Medicare are less likely to require amputation. The authors examined data from 2006 to 2015 for patients with Medicare in the "Diabetes Belt," comprising 644 counties in southeastern and Appalachian US regions with higher rates of diabetes. Patients living there had 27 percent higher odds of requiring a lower-extremity amputation versus residents of counties surrounding the belt. However, patients that used their free Annual Wellness Visit that year were 36 percent less likely to need an amputation than non-attendees, regardless of where they lived. The rates of diagnosed diabetes-related foot complications were lower in the Diabetes Belt compared with surrounding counties, which may indicate delayed diagnoses that can lead to amputations. The researchers suspect diabetic patients who participated in their Annual Wellness Visit may have had their foot complications diagnosed sooner, and they may also be more engaged in their care. They advise policymakers to prioritize incentives for Medicare beneficiaries to use these visits to help lower diabetes-related amputations.


A new West Health-Gallup survey of 6,663 US adults found at least two-thirds of older Americans feel financially burdened by healthcare costs. About 24 percent of polled Americans ages 50 to 64 call healthcare costs a major financial burden, versus 48 percent who say they are a minor burden. Fifteen percent of Americans ages 65 and older say it is a major burden compared to 51 percent calling it a minor burden. The survey also indicates that 37 percent of US adults 65 and older are extremely concerned or concerned that they will not able to cover the costs of needed healthcare services over the next year. Meanwhile, 45 percent of respondents 50 to 64 feel the same way. The poll also shows that roughly a third of Americans ages 50 to 64 are cutting back on at least one necessary expense, like food, clothing and utilities, to cover rising healthcare costs. Approximately 24 percent of adults ages 65 and older say the same.

Medicine, Drugs and Devices

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Researchers at the Indian Institute of Science and the Karnataka Institute of Endocrinology and Research have developed a set of self-regulating footwear for persons with diabetes. The footwear, a pair of specially-designed sandals, is three-dimensionally printed and can be customized to an individual’s foot dimensions and walking style. The footwear can be especially beneficial for people who have diabetic peripheral neuropathy, according to the researchers, whose findings were published in Wearable Technologies. The sandals are designed with arches that "snap" to an inverted shape when a pressure beyond a certain threshold is applied. When the pressure is removed, the arch automatically come back to its initial position. The footwear takes into account the individual’s weight, foot size, walking speed and pressure distribution to arrive at the maximum force that has to be off-loaded. Multiple arches are designed along the length of the footwear to off-load the pressure.


The US Supreme Court ruled that the federal government improperly reduced drug reimbursement payments to hospitals and clinics that serve low-income communities, costing them billions of dollars. The case the high court decided involved payments for drugs, mainly for cancer, used by Medicare beneficiaries in hospital outpatient departments. The government argued that 340B hospitals and clinics, because of their special status serving low-income communities, can purchase the drugs at a deep discount. It said reimbursing them at the same rate as other hospitals that pay more incentivized the facilities to overprescribe the drugs or prescribe costlier medications, while lowering the reimbursement would also save Medicare enrollees money in co-payments that are tied to reimbursement rates.

Justice Brett Kavanaugh wrote that "absent a survey of hospitals' acquisition costs," the US Department of Health and Human Services (HHS) "may not vary the reimbursement rates for 340B hospitals. HHS' 2018 and 2019 reimbursement rates for 340B hospitals were therefore contrary to the statute and unlawful." The American Hospital Association and other groups involved in the case called the high court's ruling a "decisive victory for vulnerable communities and the hospitals on which so many patients depend."


Established clinical guidelines hold that patients presenting with ankle issues should not receive advanced imaging ahead of standard radiography, but new research shows a substantial proportion of ordering clinicians sending these patients straight to MRI anyway. In the study, only 68 percent of around 4,200 ankle patients imaged with MRI over a nine-year period at a major academic medical center had been X-rayed ahead of the MRI within the three prior months. The study was conducted by radiologists at UC Davis Medical Center and was published in Skeletal Radiology.