News From ACFAS

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If you’re ready to take the next step in sharpening your surgical skills, register today for the Advanced Arthroscopy and Cartilage Restoration course set for July 31-August 1 in Rosemont, IL. The course is worth 16 CME.

Learn the latest techniques as well as more recent cartilage restoration from leading surgeons—arthroscopic lateral ankle ligament repair, classic OATS resurfacing and particulate cartilage resurfacing techniques, en bloc resection and replacement techniques, subtalar joint arthroscopy and arthroscopic STJ fusion technique.

To attend this course, you must have previously taken a basic foot and ankle arthroscopy course. If it wasn’t an ACFAS program, fax your certificate and agenda from the program attended to ACFAS’ Education Department at (773) 693-9304. Visit acfas.org/Skills for more information and to register. Now’s your chance to get the valuable coding and billing information you missed at ACFAS 2021 on your time. Coding and Billing for the Foot and Ankle Surgeon is now available on demand for a limited time only from July 15-August 15. To take advantage of this valuable recording, registration is required prior to watching program by visiting acfas.org.

Access this previously recorded course at your convenience for the same expert tips and insights shared at ACFAS 2021 in Las Vegas. You'll walk away with knowledge on simplifying your coding and reimbursement practices as well as 4.5 CME hours. This course covers timely topics, including what’s new in foot and ankle surgical coding, telehealth coding and addresses changes such as coding for prolonged services and several CCI edits relating to foot and ankle surgery. The ACFAS Clinical & Scientific Research Grant Program is back and officially opens on July 15! Thanks to support from PICA and the ACFAS Regions, the College is offering funding of up to $75,000 each year for an established investigator and up to $25,000 for a new researcher.

Letters of intent should be submitted by September 15 at 5pm CT and final applications are due by October 15 at 5pm CT. The application submission process officially opens on July 15. Visit acfas.org/ResearchGrant for more information. Great news—the Journal Impact Factor (JIF) for The Journal of Foot & Ankle Surgery (JFAS) increased from 1.043 in 2019 to 1.286 in 2020! The JIF is a journal metric, which measures the success of a journal. Many factors are taken into account including the volume of publication and citations, characteristics of the subject area and type of journal. JFAS’ steadily increasing JIF over the years is great news for the Journal and its visibility. Thank you to editor D. Scot Malay, DPM, MSCE, FACFAS, deputy editor Naohiro Shibuya, DPM, MS, FACFAS and the entire editorial board for their efforts to increase the value and visibility of the Journal!

Foot and Ankle Surgery

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A retrospective cohort study aimed to fill in gaps in Australian data concerning the duration of total contact casting (TCC) for resolution of acute Charcot foot and the role of any patient and clinical factors. The analysis involved 27 patients with acute Charcot foot attending for TCC treatment at a high-risk foot service (HRFS) in a large metropolitan health network in Melbourne. The average age of patients was 57.9 years, 66.7 percent were male, 88.9 percent were diabetic, 96.3 percent had peripheral neuropathy and 33.3 percent had peripheral arterial disease. Charcot misdiagnosis happened in 63 percent of participants, and signs and symptoms consistent with acute Charcot foot were present for an average two months before presenting or being referred to the HRFS. All patients had stage one Charcot foot, with most located in the tarsometatarsal joints or midfoot and induced by an ulcer or traumatic injury. The median TCC duration for resolution of acute Charcot foot was 4.3 months, with an overall complication rate of 5 percent per cast.

Skin rubbing/irritation and asymmetry pain were the most frequent complications from TCC, and osteoarthritis was significantly associated with a TCC duration of over four months. Following TCC treatment, 48.1 percent of patients returned to footwear with custom foot orthoses, 25.9 percent used a life-long Charcot Restraint Orthotic Walker and 22.2 percent underwent soft tissue or bone reconstructive surgery. No Charcot recurrences were observed, while three patients had contralateral Charcot.


The randomized controlled FOotCAre Trial II was performed to evaluate the feasibility of design, adherence, satisfaction, safety and changes in outcomes followed by a home-based foot–ankle exercise for individuals with diabetic peripheral neuropathy (DPN). A control group (CG) received usual care while an intervention group (IG) received usual care and home-based foot–ankle exercises for eight weeks. In the initial 20 weeks, 1,310 individuals were screened for eligibility by phone contact, and the contact rate was 89 percent, preliminary screening rate was 28 percent and recruitment rate was 1.0 participants/week, trailing the ideal rate of five participants/week. Compliance with the exercise program was 77 percent, and the respective IG/CG dropout rates were 11 percent and 9 percent. IG participants' average level of satisfaction was four and perceived safety was three, and IG significantly decreased DPN severity, elevated hallux relative to forefoot range of motion and decreased maximum forefoot relative to hindfoot dorsiflexion during gait.


New research sought to investigate the functional constraints after first metatarsal phalangeal joint (MTPJ) arthrodesis using a compression screw/locking plate, overall satisfaction and patient's abilities to realize activities of daily living (ADL). The study involved 103 participants who underwent a first MTPJ arthrodesis under the care of a single surgeon. Follow-up was over 12 months, with one non-union in the cohort while two patients experienced delay to fusion. Meanwhile, 97.1 percent of patients were very satisfied with the procedure and their ability to achieve ADL post-operatively, while 82.5 percent could resume wearing non-adaptive footwear. The mean hallux valgus angle and inter metatarsal angle reduction was 21.78 degrees and 6.84 degrees, respectively. The results offer clear evidence of high post-procedural levels of functionality with statistically significant differences in all four aspects of the American Orthopaedic Foot and Ankle Score questionnaire and several notable differences in activity levels and footwear restrictions pre- and post-operatively.

Practice Management

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Self-employed physicians and medical practice owners can assess their risk of being sued for malpractice by understanding various trends. Male physicians are sued more frequently than women, with 68 percent of lawsuits against male physicians to 32 percent against women. As the numbers of women grow in certain specialties, lawsuits against women physicians may also rise. Meanwhile, the amount of malpractice awards has been steadily climbing, with one report finding that the percentage of medical malpractice claims topping $500,000 rose from less than 10 percent in 1999 to almost 20 percent in 2017. Meanwhile, an American Medical Association study found the likelihood of litigation increases with age, as does the probability of being sued multiple times. Finally, employed physicians and owners face equal risks of litigation, and practice employees are more likely than owners to have had multiple claims filed against them.


Independent doctors are embracing the price transparency push, by posting their prices online via user-friendly software platforms. A key reason for this widescale adoption is the fact that independent practices' prices look terrific compared to hospitals' charges for the same services. The cost of a procedure performed by an independent doctor in a freestanding clinic is generally one-third to one-tenth that of the same procedure performed by hospital physicians. As more independent doctors use price transparency, more patients will consider such providers as offering far better value than their hospital-employed counterparts. Furthermore, most analysts concur that once healthcare price transparency is widespread, competition will intensify and prices for care and coverage will plunge.

Health Policy and Reimbursement

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Nevada has broadened its role in healthcare through a new law that is seen as an experiment in how healthcare might unfold nationwide in the future. The state's Democratic lawmakers say the law will lower costs for consumers by creating a "public option" in which private insurers offer lower-priced health plans, despite claims by Republicans and healthcare industry officials that it could drive medical providers out of business. Under the law, some insurers must bid to offer plans starting in 2026 on the public option, with the goal being to have these plans priced 5 percent less than other mid-priced plans by average that adhere to the Affordable Care Act (ACA). The objective is to have the public-option plans priced at 15 percent lower over four years, and insurers that administer Nevada's large Medicaid contracts must bid with the state to offer plans through the public option to many individuals whose income is sufficiently low to qualify for ACA subsidies, as well as small businesses. The ordinance would realize lower costs by paying doctors, hospitals and other providers less than what private insurers currently reimburse, although health workers would be paid no less than Medicare reimbursement rates. Some doctors opposed to the public option are concerned that it will push more physicians away from government-run insurance, pressuring those who still stick with them. Advocates, on the other hand, say hospitals will see smaller losses related to treating the uninsured, since more residents will be covered.


The US Supreme Court refused to hear a bid by health insurers to seek full reimbursement from the federal government under a provision of the Affordable Care Act (ACA) statute aimed at encouraging them to provide medical coverage to uninsured Americans. The justices rejected appeals by Maine Community Health Options, Community Health Choice and Common Ground Healthcare Cooperative, who claimed they were collectively owed millions for each year they did not receive payments the government had promised under ACA. The high court retained an August 2020 ruling by the federal appeals court that their reimbursement for money owed could be compensated by premium tax credits. In April 2020, the Supreme Court ruled in a related case that the federal government must "honor its obligations" and pay various private insurers up to $12 billion owed to them. This concerned reimbursements via the law's risk corridor program designed to mitigate insurers' risks from 2014 to 2016, when they sold coverage to previously uninsured people through exchanges established under the ACA. The latest case was focused on a separate provision mandating that the government recoup insurers for cost-sharing payments like deductibles and co-payments, whose termination the Trump administration announced in 2017. Litigation will now proceed in lower courts.

Medicine, Drugs and Devices

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An algorithm designed by leading US electronic health record provider Epic Systems to forecast sepsis infections is significantly lacking in accuracy, according to an analysis of data on about 30,000 patients in University of Michigan (U-M) hospitals. U-M researchers said the program overlooked two-thirds of the approximately 2,500 sepsis cases in the data, rarely detected cases missed by medical staff and was prone to false alarms. The researchers said Epic tells customers its sepsis alert system can correctly differentiate two patients with and without sepsis with at least 76 percent accuracy, but they determined it was only 63 percent accurate. U-M's Karandeep Singh said the study highlights wider shortcomings with proprietary algorithms increasingly used in healthcare, noting that the lack of published science on these models is "shocking."


Medicare spent $560 billion on prescription drugs during 2016–18, according to the US Government Accountability Office (GAO), with 58 percent of those dollars going to drugs promoted through direct-to-consumer advertising (DCTA). GAO found that DCTA almost exclusively targeted brand-name medications. It also observed that some of the medications with the greatest DCTA investment were among the products garnering the highest spending by Medicare Parts B and D.


A new study in JAMA Network Open found many older Americans are still taking a daily baby aspirin to prevent first-time heart problems, even though current guidelines discourage this. Fifty to 62 percent of US adults aged 70 and up were using low-dose aspirin to reduce their risk of heart disease or stroke, and the drug was also used commonly among those with no history of heart disease. Johns Hopkins University School of Medicine Professor Rita Kalyani said current American College of Cardiology/American Heart Association guidelines generally advise people aged 70 and older against routinely taking aspirin to prevent a first-time heart attack or stroke. Aspirin carries a risk of bleeding in the gastrointestinal tract or even the brain, and these risks usually increase with age. Moreover, recent trials have failed to demonstrate that low-dose aspirin actually reduces the odds of first-time heart attacks or strokes. DARTNet Institute Chief Medical Officer Wilson Pace recommends statins as a preventive measure for primary heart disease.