News From ACFAS

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ACFAS and Foot Health Facts are now on Instagram! Follow us at @ACFAS.Foot.and.Ankle.Surgeons for news and photos from the College and at @Foot.Health.Facts for foot and ankle health info you can share with your patients.

As part of this debut, ACFAS has launched a #KeepYouOnYourFeet social media awareness campaign to show how foot and ankle surgeons help keep people “on their feet.” Share with us photos of your feet hard at work, on vacation or exploring the world using #KeepYouOnYourFeet in your posts.

Be sure to also encourage your patients to post photos of their feet with the #KeepYouOnYourFeet hashtag. Don’t just follow the latest research trends—lead them by submitting your original research study to The Journal of Foot and Ankle Surgery (JFAS).

Published bimonthly and peer-reviewed, JFAS is considered the top source for clinically focused articles on surgical and medical management of the foot and ankle. JFAS also allows you to publish your work as an Open Access article to give your research the widest reach possible.

Tap into this targeted audience of foot and ankle surgeons, podiatrists, orthopaedic surgeons and other medical specialties that look to you for guidance on new surgical techniques and approaches to improve patient care.

Visit the newly redesigned jfas.org to learn how to submit your article for consideration. New graduates, join ACFAS for free and jumpstart your career development! Thanks to the support of our local Regions, first-year podiatric surgical residents receive a complimentary first-year membership to the College. Take advantage of all member benefits, including special pricing on conferences, products and services, free for one year (a $120 value).

Enjoy access to acfas.org, the College’s premier website, and a subscription to the online version of The Journal of Foot & Ankle Surgery (JFAS), your source for the latest surgical techniques and research.

The resident membership year runs from September until October. Join now and get July and August included as a bonus!

Foot and Ankle Surgery

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One method of fixation for syndesmotic ankle injuries is the suture button technique, but cost limits the use of commercially available options. Researchers designed an inexpensive and readily available alternative suture button construct for treatment of syndesmotic ankle injuries.

The researchers followed 47 patients for a minimum of 24 months. They assessed pre- and postsurgery American Orthopedic Foot and Ankle Society (AOFAS) scores along with reported complications and postoperative radiological analysis. The researchers utilized polyester braided surgical sutures jointly with double mini two-holed plates, a No. 2 polygalactin 910 suture, a 4 mm drill bit and a 15 cm long suture needle with slotted end. This technique was supported with the use of the image intensifier.

The AOFAS score improved significantly from a mean of 32.4 to 94.2 (P=0.004). Radiologically, the medial clear space, tibio-fibular clear space (P=0.05) and tibio-fibular overlap measurements showed a significant improvement postoperatively (P=0.02). Patients reported good satisfaction rates with a 96 percent success rate (95 percent CI: 94.0 percent to 99.3 percent).

The researchers concluded that this low-cost suture button construct is a simple, safe and cost-effective treatment option for acute syndesmotic injuries.


In this study, researchers examined the efficacy of neuro-orthopaedic surgery for spastic equinovarus foot (SEF) after stroke based on a goal-centered approach and on the three domains of the International Classification of Functioning, Disability and Health (ICF).

The study included 18 hemiplegic patients with SEF. A selective tibial neurotomy and/or an Achilles tendon lengthening and/or a tibialis anterior tendon transfer were performed to correct a disabling SEF. The primary outcome measure was the goal attainment scale. The secondary outcome measures included body function and structure, activities and social participation and quality of life assessment. Outcomes were measured before surgery as well as two months and one year after surgery.

Researchers discovered an increase in the goal attainment scale score and in the body function and activity/participation domains of the ICF. They also observed a decrease in triceps spasticity and pain, an increase in ankle range of motion and gait speed, an improvement in equinus and a reduction in walking aids.

This study confirms the efficacy of the neuro-orthopaedic surgical treatment of SEF after stroke to enhance walking capacities and to achieve personal goals in the body function and activity/participation domains of the ICF.


The aim of this study was to assess the effects of two arthroereisis implants for the correction of bilateral flexible flatfoot (FFF) on foot and lower limb biomechanics during gait.

Thirteen children affected by bilateral symptomatic FFF underwent bilateral subtalar arthroereisis during the same surgery using two types of poly-L-lactide bioabsorbable implants: an expanding endo-orthotic implant and a calcaneo-stop screw. At one-year follow-up, all radiological parameters and frontal-plane orientation of the rearfoot in double-leg standing were improved in both implant groups (e.g., calcaneo-stop: pre-op = 15 ± 7 deg; post-op = 6 ± 9 deg; p < 0.01). The endo-orthotic implant group showed significantly lower pronation/supination at the ankle and midtarsal joint. Activation of the tibialis anterior muscle was more physiological after surgery in both groups.

This study demonstrated that both implants appear effective in restoring physiological alignment of the rearfoot; however, the endo-orthotic implant appeared more effective in restoring a more correct frontal-plane mobility of foot joints.

Practice Management

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Virtual assistants, such as Apple's Siri and Amazon's Alexa, are growing in popularity, but physicians and healthcare professionals should be careful not to bring them into the office just yet. Although it may be tempting to use their functions for note taking, web research or accessing medical records, these devices are not yet in compliance with the Health Insurance Portability and Accountability Act (HIPAA).

The goal of HIPAA is to protect patients' private health information, the most sensitive and underprotected data in the world today. Ransomware hackers have increasingly targeted hospitals and physician offices for this reason, especially solo and small medical practices, which tend to reduce spending on information technology. This software will inevitably need to jump through some more hoops before being allowed in a hospital room and access to medical records. While Google and Amazon have worked on making their cloud services compliant with HIPAA's standards, neither smart speaker with their respective virtual assistant is currently HIPAA compliant.

Physicians, hospitals and practices should proceed for the time being as if these devices are not HIPAA-compliant. Failure on the part of physicians to secure medical record data can not only cost them hundreds of thousands of dollars, but also make it easier for hackers to commit identify theft.


The effects of a data breach can be devastating on a healthcare organization, from regulatory fines and penalties to public backlash that damages the company's reputation. To secure sensitive healthcare communications, first develop a set of rules and policies for how employees must handle patient data. Document this corporate governance policy, distribute it across your company and then conduct mandatory training for all of your staff.

Second, train employees to be aware of hackers' most common scams and to be smart about dealing with emails, websites, suspicious links and file downloads. Third, limit your staff to a list of secure apps for messaging and collaboration. Even apps designed to transmit data through the cloud will often maintain copies on the app makers' own servers, so make sure to look for services that will protect your data once it is in cloud storage.

Fourth, upgrade your in-house fax infrastructure to a HIPAA-compliant fax service. Faxing is still one of the most commonly used communication methods in today's healthcare industry, but it is vulnerable to patient data leaks and even HIPAA violations. A better approach is to outsource your entire fax infrastructure to a reliable and trusted cloud fax service provider. Finally, stay current on the latest data breach threats and hold regular company-wide updates to make sure everyone in your organization knows about them, too.


Certified Physician Assistants (PAs) can help combat the issues of provider shortages and physician burnout. Full-time PAs treat an average of 73 patients per week, according to the newest Statistical Report on Certified PAs published by the National Commission on Certification of Physician Assistants. They often accept same-day and walk-in appointments, thus reducing physician workloads and boosting patient satisfaction.

One way PAs can help manage patients is by providing some of the same services as physicians. Certified PAs must pass a rigorous exam to practice, are required to pass written assessments every decade and must complete continuing medical education every two years. They order and review lab tests, prescribe medications, make referrals and counsel patients. In addition, PAs can handle administrative and preventive tasks and visits, such as risk-adjusted coding, quality improvement and Medicare Annual Wellness Visits. This can relieve physicians from some important operational tasks while increasing the revenue to the practice and the quality of preventive care provided to the patient.

Furthermore, PAs can focus on a niche specialty within the practice, effectively becoming the resident expert in that area. This will typically improve patient care and free up the physician to focus on more acute or complex cases. Finally, PAs can address specific visit types, such as focusing on procedures, preoperative assessments, counseling and managing postoperative care.

Health Policy and Reimbursement

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Medicare officials are soliciting feedback on how to revise physician self-referral rules to help reduce healthcare costs. The 1989 Stark Law largely prohibits doctors from referring clients to care settings where they could see some financial gain. The law and subsequent regulations were put in place to prevent unnecessary care, but conservative lawmakers claim they could be impeding better care coordination and controlled spending. For example, if a physician-led accountable care organization wants to treat someone in a lower-cost surgery center instead of a hospital, the current rules may bar such a referral.

The U.S. Department of Health and Human Services (HHS) is requesting information on how Stark regulations hinder care coordination and how to surmount those obstacles while ensuring that self-referrals would be transparent and not unnecessarily raise costs. U.S. Centers for Medicare and Medicaid Services Administrator Seema Verma notes she is seeking out "bold ideas," while HHS Deputy Secretary Eric Hargan is spearheading this effort. Comments are due on August 24.


Under a new rule released by the Trump administration, millions of small businesses and self-employed individuals will be able to purchase health insurance plans exempt from many Affordable Care Act (ACA) consumer protections—making it easier to band together and get "association health plans" for themselves and their employees. Many of the plans will be subject to the same rules as bigger employers, which means they will not have to provide comprehensive benefits, such as maternity services, prescription drugs or mental healthcare, mandated under the ACA. That is expected to lead to lower prices for people who enroll.

The move has been praised by Republicans and some business groups that say it will give small employers the flexibility to cover workers at a lower cost. Democrats, meanwhile, argue that it would increase costs for people with preexisting conditions and people who buy their own coverage on the individual market.

While premiums for association plans will likely be significantly cheaper, costs for consumers who buy their own coverage on the individual market are expected to rise, analysts say. Those higher premiums are predicted to increase the number of Americans without coverage.


The Trump administration is expected to announce a federal reorganization plan that will include a consolidation of safety-net programs under a rebranded U.S. Department of Health and Human Services (HHS). The plan calls for renaming HHS the Department of Health and Public Welfare and shifting the $70 billion food stamp program out of the U.S. Department of Agriculture (USDA) to the new agency.

These changes are part of a sweeping government restructuring envisioned by Office of Management and Budget Director Mick Mulvaney. HHS currently oversees Temporary Assistance for Needy Families, which provides cash aid to low-income households and Medicaid, which offers health coverage for more than 70 million Americans. The Heritage Foundation think tank in 2017 recommended that USDA nutrition programs, including food stamps, nutrition education and school meal programs, be transferred over to HHS.

Medicine, Drugs and Devices

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The House has passed H.R. 5773, a bill requesting technological changes that may lead to an overhaul for the Medicare drug plan prescription preauthorization process. One section of the Preventing Addiction for Susceptible Seniors Act of 2018 urges the secretary of the U.S. Department of Health and Human Services (HHS) to have an electronic preauthorization system for Medicare Advantage plans and Medicare Part D prescription drug plans implemented by January 1, 2021. Another section would call for encouraging Medicare Advantage plans and Medicare Part D drug plans to expand the use of electronic preauthorization systems. The bill says expanding usage of the systems should "reduce access delays, by resolving coverage issues before prescriptions for such drugs are transmitted."

The legislation would also require Medicare plans to make high-risk enrollees eligible for medication therapy management program benefits by January 1, 2021, and it instructs the HHS secretary to develop a program to warn Medicare Part D prescribers if the providers were prescribing more opioids than comparable providers. In addition, the HHS secretary would be required to establish a website that Medicare drug plans could use to share information about possible fraud, waste and abuse with the department and each other. Mark Farrah Associates estimates that about 43.5 million Americans have drug benefits from a Medicare Advantage plan or a Medicare Part D drug plan.


A nonprofit advocacy group is asking the U.S. Food and Drug Administration (FDA) to remove a gout drug from the market after research revealed potentially fatal risks to patients. In a citizen petition, Public Citizen stated that there is "overwhelming evidence that the serious cardiovascular harms of Uloric (febuxostat) outweigh any purported clinical benefit." It cited the results of a postmarketing study published in the New England Journal of Medicine in March that discovered higher rates of fatal cardiovascular events and all-cause mortality in patients taking the drug.

FDA ultimately approved Takeda Pharmaceuticals' new drug application for Uloric in 2009, but it required the company to conduct a randomized, controlled postmarketing study to examine whether the drug has a greater risk of serious adverse cardiovascular outcomes compared to a widely used gout treatment called allopurinol.

Based on preliminary results from the postmarketing study, FDA issued a safety communication in November warning that Uloric "showed an increased risk of heart-related deaths and deaths from all causes." Then in March, Takeda announced the publication of its postmarketing study. It found that although the rate of major cardiovascular adverse events was similar between patients treated with Uloric and those treated with allopurinol, the rate of cardiovascular deaths was higher in patients treated with Uloric.


A new RAND Corporation study published in the Journal of General Internal Medicine is the first to examine various subtypes of risky prescribing of opioids and tie such prescribing to a broad array of deadly outcomes. The researchers examined prescription records for residents of Massachusetts over five years, identifying six types of risky prescriptions. More than 6 percent of Massachusetts adults were given a risky opioid prescription during the study period.

The subtypes of risky prescribing of opioids included high-dose opioid prescriptions; prescribing of opioids along with the anti-anxiety medication benzodiazepines; opioids prescribed to someone by four or more prescribers in a calendar year; filling opioid prescriptions at four or more pharmacies per annum year; paying cash for an opioid prescription three or more times over three months; and prescribing opioids without documentation of a pain diagnosis.

More than 50 percent of Massachusetts adults received at least one opioid prescription between 2011 and 2015, and more than 11 percent of those individuals experienced at least one kind of risky opioid prescription. Moreover, more than 13 percent of subjects age 80 and older received at least one prescription, which contradicts the public image of the opioid crisis as a problem among young people. The strongest linkage to any cause of death was receiving a high-dose prescription for opioids and lacking a documented pain diagnosis. Five of the six risky prescription subtypes were associated with a fatal opioid overdose, with the exception being making cash payments for opioids.