News From ACFAS

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Deadlines are quickly approaching to be a part of ACFAS 2023! The College is looking for high-quality posters and manuscripts to be presented at the Annual Scientific Conference, February 9-12 in Los Angeles.

If you’re currently involved in a study that would be beneficial to the profession, submit yours by the end of today, August 3 for a chance to present it in Los Angeles in February. Manuscript winners will divide $10,000 in prize money

Poster abstracts must be submitted to ACFAS by September 7 to be eligible for review. PDFs of eligible posters are due November 9.

Visit acfas.org/asc for more information, to view guidelines/criteria and submit your poster or manuscript today! The ACFAS Fellowship Committee recently determined the following fellowship exceed the minimal requirements to be reinstated to Recognized Status with the College after a one-year hiatus:

Associates in Medicine and Surgery Sports Medicine and Reconstructive Surgery Fellowship
Fort Myers, Florida
Program Director: Eugene Batelli, DPM, FACFAS

Also, the following six new fellowship applicants have been granted Conditional Status* with ACFAS:

San Antonio Sports Medicine Associates Foot & Ankle Surgical Fellowship
San Antonio, Texas
Program Director: Marque Allen, DPM, FACFAS

Puerto Rico Foot and Ankle Reconstructive Surgical Fellowship
San Juan, Puerto Rico
Program Director: Carlos Arroyo-Romeu, DPM, FACFAS

Saint Josephs Medical Center Limb Salvage & Hyperbaric Medicine Fellowship
Yonkers, New York
Program Director: James De Meo, DPM, FACFAS

Washington Orthopaedic Center Advanced Reconstructive Foot and Ankle Surgery Fellowship
Centralia, Washington
Program Director: Michael Dujela, DPM, FACFAS

Foot and Ankle Physicians of Ohio Fellowship
Grove City, Ohio
Program Director: Elizabeth Hewitt, DPM, FACFAS

Nebraska Foot and Ankle Reconstructive Surgery Fellowship
Hastings, Nebraska
Program Director: David E. Waters, DPM, FACFAS

*All new Conditional Status programs are considered for Recognized Status with ACFAS after they have received status and the first fellow completes the program.

ACFAS highly recommends taking on a specialized fellowship for the continuation of foot and ankle surgical education after residency. If you are considering a fellowship, visit acfas.org/FellowshipListing to review a complete listing of programs and minimal requirements. Residents, another Comprehensive Fixation for the Ankle and Foot: A Resident’s Course is coming November 9-10. Don’t miss the opportunity to join us for a deep dive into podiatric internal fixation surgery.

This course offers a small resident to faculty ratio allowing for close mentorship, and a redesigned agenda focused on shorter lectures with ample time for hands-on learning. With this course, you’ll gain real-life experience in:

• Major rearfoot and ankle arthrodesis techniques
• Complications that can result from internal and external fixation
• Specialty plating and external fixation techniques
• Preoperative planning

Visit acfas.org/skills for more information and to register today!

Foot and Ankle Surgery

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Researchers examined the morphology of the Lisfranc joint in cadavers, dissecting 22 embalmed cadaveric feet (13 male, nine female, age 80.3 years ± 14.03) to isolate the bones and ligaments of the Lisfranc joint. The dissected dorsal Lisfranc ligament had consistent morphology and the interosseous Lisfranc ligament had a consistent path, although 11 of 17 specimens had a connection to the plantar Lisfranc ligament. The plantar Lisfranc ligament exhibited wide variability with a Y-variant and a fan-shaped variant, and ligament thickness was greatest in the interosseous Lisfranc ligament and least in the dorsal Lisfranc ligament. This analysis suggests variations of the interosseous and plantar Lisfranc ligament may contribute to joint injury susceptibility, while arthritic changes to the joints raise question concerning the prevalence of arthritis in the uninjured Lisfranc joint.


A systematic review concentrating on Achilles tendon repair looked at rerupture and wound complication rates following the procedure. Treatments were categorized as open minimally invasive, open standard and nonoperative. Significantly higher complications for minimally invasive compared to nonoperative treatment were observed. Patients in the minimally invasive treatment category saw significantly lower rerupture rates compared to those receiving nonoperative treatment. Those who underwent nonoperative treatment had a significantly lower rerupture rate compared to open treatment. No significant difference in rerupture rates was seen in comparing minimally invasive to open standard treatment.


A retrospective cohort study was held to compare the subtalar arthrodesis union rate of patients with native tibiotalar joints to that of individuals with prior tibiotalar arthrodesis. The authors also evaluated nonunion risk factors. There were 18 patients with an adjacent ankle arthrodesis compared to 53 patients who without. The successful subtalar arthrodesis union rate in those with a preexisting ankle joint arthrodesis (44.4 percent) was roughly half that in those without an ankle joint arthrodesis (86.8 percent). Multivariate logistic regression showed an adjacent ankle arthrodesis to be the sole significant risk factor for nonunion. The odds ratio of nonunion of the subtalar joint with an adjacent ankle arthrodesis present was 4.90 versus a subtalar arthrodesis with a native ankle joint. Moreover, 9.4 percent of patients without an ankle arthrodesis received a revision subtalar arthrodesis versus 44.4 percent of those with an adjacent ankle arthrodesis. The researchers concluded that patients with a previously fused ankle require counseling about the high risk of nonunion and the possibility of additional surgery.

Practice Management

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To determine whether high childcare stress (CCS) is associated with burnout, intent to reduce (ITR) clinical hours and intent to leave the job (ITL) among US healthcare workers (HCWs) during the COVID-19 pandemic, researchers polled 58,408 HCWs. Participants responded with a median organizational response rate of 32 percent, and CCS was present in 21 percent of respondents. It occurred more frequently among racial and ethnic minority individuals and those not identifying race or ethnicity compared to white respondents and among women versus men. Respondents with CCS had 115 percent greater odds of anxiety or depression and 80 percent greater odds of burnout compared to individuals without CCS. High CCS was affiliated with 91 percent higher odds of ITR and 28 percent higher odds of ITL. "Addressing CCS may improve HCWs' quality of life and HCW retention and work participation," the authors suggested.


Researchers used 2019 survey data to quantify primary care physicians' (PCPs) perceptions of communication at the time of referral and after consultation, uncovering lingering gaps in communication. The similarity between the 2019 survey and an earlier one in 2008 suggests physicians still do not consistently communicate with each other about the patients they have in common. In all, 22 percent of PCPs participating in the Comprehensive Primary Care Plus model (Track 1) and non-participating physicians (Track 2) reported that they either "sometimes" or "seldom or never" send clinical information to the specialist at the time of a referral. Moreover, 35 percent of Track 1 and 33 percent of Track 2 PCPs said they either "sometimes" or "seldom or never" receive information back from the specialist following consultation. "Our findings underscore the need for granular measurements of how communication is changing," the authors concluded. "It is not enough to assume that putting EHRs in place will improve communication; changes in communication need to be measured."


Medical practices considering transitioning to a concierge model should weigh legal and compliance issues. Potential snags include patient agreements, which could make services unaffordable for certain patients, who will still try to pay with insurance. Practices should understand and vet the payor agreement to avoid violating the contract and refrain from concierge services that may be covered by a third-party payor agreement. Some provider arrangements may appear more like insurance agreements, and insurance laws in most states have several requirements before any person can offer concierge services; an attorney must therefore review the state's insurance licensure laws and provide a summary before drafting a provider-patient agreement.

Concierge practices offering free services raise concerns under the federal antikickback statute if Medicare participates or state antikickback laws. Practices should also check how they are separating from patients who do not join concierge services. They should supply adequate notice to patients of the new model and give them sufficient time to find another provider if they choose not to follow the new business model. Practices should review state patient abandonment laws to maintain compliance with any state regulation.

Health Policy and Reimbursement

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The US Department of Health and Human Services' Office of Inspector General (OIG) has issued a fraud alert for physicians entering telemedicine arrangements. The OIG issued the special warning July 20, the same day that the US Justice Department charged 36 people in schemes involving $1.2 billion in fraudulent telemedicine, durable medical equipment and cardiovascular and cancer testing. Among suspicious characteristics to look out for are patients who are recruited by the telemedicine company, a lack of sufficient information from the patient to assess the medical necessity of items or services, telemedicine companies that pay the physician based on volume of items or services and telemedicine companies that only offer items and services to federal payers and don't accept private insurance.


US Senate democrats have reached a deal to extend enhanced Affordable Care Act (ACA) subsidies for three years through 2025. The deal is part of a larger $300 billion package announced late Wednesday that will also give Medicare narrow authority to negotiate prescription drug prices. If the legislation becomes law, it will avoid a major cliff that could spark double-digit spikes in premiums starting next year. The American Rescue Plan Act boosted ACA subsidies for the 2021 and 2022 coverage years. The new subsidies, which helped ensure some low-income Americans pay nothing in premiums, contributed to a record-breaking 14.5 million sign-ups on the exchanges for 2022. The Biden administration has been pressing Congress to extend the subsidies, saying insurers need to know soon whether the enhanced subsidies will be there as they are formulating rates now.


Ahead of the US Centers for Medicare and Medicaid Services' (CMS) release of the final rule on inpatient payment, US House and Senate members are urging CMS to increase the rate hospitals will be paid. A bipartisan group of 112 representatives and 30 senators have asked CMS to consider using its special exceptions and adjustments authority to revise the hospital inpatient prospective payment system rule for fiscal year 2023 to more accurately reflect the cost of providing hospital care to patients. Several other senators have separately urged CMS to address similar concerns. The House and Senate letters have expressed concern that CMS' proposed rule does not fully account for the current cost of care and would result in an overall payment reduction for hospitals.

Medicine, Drugs and Devices

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The US Food and Drug Administration (FDA) proposed a revision to the National Drug Code (NDC) that involves using a 12-digit format in place of the current 10-digit format because these codes are expected to be used up within the next 10-15 years. The agency said it will not require industry to "resubmit all of their drug existing drug listing files to convert the NDCs from one of the discontinued 10-digit formats to the new, uniform, 12-digit, six-four-two format. Instead, FDA intends to convert existing NDCs on its own, on the effective date, by adding leading zeros to the appropriate segments." FDA noted that NDCs are used across the healthcare system and these changes will "impact human and animal drug manufacturers, insurers/payors, wholesale distributors, drug databanks, pharmacies, hospitals, small clinics and healthcare practitioners."


The US Department of Health and Human Services Cybersecurity Coordination Center (H3C) has issued new guidance on healthcare web app attacks and remediation strategies. Web app attacks typically depend on stolen credentials or exploit known flaws, and the most common healthcare-related web app attacks transpire on patient portals, telehealth platforms, online pharmacies, electronic health records, health entities' web-based email and similar technology. Distributed Denial of Service attacks against healthcare are often driven by political, hacktivist or financial gain and involve extortion; such attacks are particularly impactful in healthcare given the deluge of network traffic that renders resources and web apps unusable. HC3 is concerned that these exploits can "impact the confidentiality, integrity and availability of healthcare applications, systems, data and resources."

Healthcare entities should review the HC3 report to identify tools and tactics used to exploit public-facing apps, along with the malefactors who target these vulnerabilities to support a proactive remediation plan. The key defense against web app attacks is to build websites that can operate as expected even when under siege. "The concept involves a collection of security controls engineered into a web application to protect its assets from potentially malicious agents," HC3 states. The group also recommends automated vulnerability scanning, web app firewalls and secure development testing where "security teams consider the threats and attacks that might have an impact on an application or product to help make it as secure as possible."


Researchers at the University of Michigan found that prescription rates for non-opioid analgesics have been increasing in recent years. They conducted a study to evaluate insurance data claims from more than 15 million US patients to determine if 2016 opioid guidelines from the US Centers for Disease Control and Prevention had any effect on prescription rates for non-opioid medications such as acetaminophen, nonsteroidal anti-inflammatory drugs, antidepressants and anti-seizure medications. Among other things, the guidelines discussed the selection, dosage, duration, follow-up and discontinuation of opioid analgesics and their potential risks. The study revealed that rates for non-opioid prescriptions increased 3 percent one year after the guidelines were implemented, rising to 8.7 percent after 2 years and 9.7 percent after 3 years.