News From ACFAS

---

The ACFAS Nominating Committee seeks experienced members to serve on the College’s Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to help lead the profession, send your nomination application by September 15.

Visit acfas.org/nominations for the nomination application and complete details on the recommended criteria for candidates. For more information, contact ACFAS Executive Director Patrick (PJ) Andrus at pj.andrus@acfas.org Questions regarding eligibility criteria should be directed to Nominating Committee Chair Christopher Reeves, DPM, FACFAS at docreeves1@yahoo.com.

The Nominating Committee will announce recommended candidates to the membership no later than November 27, 2020. Candidate information and ballots will be emailed to all voting members no later than December 11. Electronic voting ends on December 28. We’re releasing a new clinical session each month to continue bringing you more e-learning opportunities from ACFAS! Videos of past sessions are freely available to members to supplement any continuing education hours needed. Check out the newest addition to our library and what’s coming up next:

• July: Convincing the Skeptic—Diabetic Foot
• August: Optimizing Arthrodesis
• September: Debating the Bunion: Surgical Decision Making in the “Grey” Areas

New sessions are released on the 15^th of each month, so check back to make sure you don’t miss another free learning opportunity. Visit the ACFAS OnDemand learning portal at acfas.org/OnDemand to access all available clinical sessions and other e-learning resources. The ACFAS Board of Directors approved a revision to the Total Ankle Reconstruction (TAR) Privileging Guidelines. The College strongly recommends that these guidelines, or their equivalence, be utilized for all surgeons performing TAR procedures at all institutions.

Share this latest guideline with your hospital to help gain TAR surgical privileging. For the full guideline and other guidelines and position statements, visit acfas.org/positionstatements.

Foot and Ankle Surgery

---

The study explored the relationships between claw toe deformity, peripheral neuropathy, intrinsic muscle volume and plantar aponeurosis thickness using computed tomography images of diabetic feet in a cross-sectional analysis. Forty randomly-selected subjects with type 2 diabetes were selected for each of the following four groups: peripheral neuropathy with claw toes, peripheral neuropathy without claw toes, non-neuropathic with claw toes and non-neuropathic without claw toes. Subjects with concurrent neuropathy and claw toes had thicker mean plantar aponeurosis and may have had less mean intrinsic muscle volume than the other groups. The effects of neuropathy and claw toes on aponeurosis thickness were synergistic rather than additive. A similar pattern may exist for intrinsic muscle volume, but results were not as conclusive. A negative correlation was observed between plantar aponeurosis thickness and intrinsic muscle volume.


Authors tried to decrease the numbers of nonunion after first metatrsophalangeal joint (MTP-1) arthrodesis in their clinic. They aimed to do this by raising awareness for the problem, making a uniform surgical treatment protocol, banning the commonly used convex-concave reamers and promoting solely the use of hand instruments to prepare the joint. The study analyzed all 53 patients who underwent MTP-1 fusion between January 2018 and March 2019, who were treated according to a standardized protocol. The incidence of nonunion was 3.8 percent, significantly lower than the 24.1 percent in 2015 to 2016. Multivariate regression analysis showed a 7.11 times higher risk of nonunion in 2015 to 2016 compared with 2018 to 2019. Furthermore, an increase of 10 degrees in hallux valgus angle (HVA) showed a 1.52 risk of occurrence of nonunion.

The use of convex/concave reamers was univariately associated with a 3.61 times higher risk of nonunion. But after correction for preoperative HVA, the preparation method was no longer associated with the occurrence of nonunion. Patients suffering from severe hallux valgus had nonunion in 32.1 percent of cases. Incidence of nonunion after MTP-1 arthrodesis was significantly reduced by raising awareness and by standardizing the treatment protocol. There was no significant difference in nonunion frequency between the methods of joint surface preparation.


Deep infection after open reduction internal fixation (ORIF) of ankle fractures represents a challenge to the orthopaedic surgeon. The study assessed the results of a modified technique of tibiotalocalcaneal fusion using a retrograde locked intramedullary nail covered in cement with antibiotics. Six patients with a mean age of 64.2 years treated using the authors' technique were analyzed retrospectively. All patients had deep infection after ankle osteosynthesis and several surgical procedures had failed. Tibiotalocalcaneal stability and eradication of the infection were achieved in all patients, along with the normalization of clinical and radiologic parameters. In the patient who underwent a talectomy, one of the calcaneal locking screws broke, with no clinical repercussions. Tibiotalocalcaneal fusion with antibiotic cement-coated retrograde nails was useful in providing clinically acceptable results in the control of chronic infection in complex patients after the failure of previous surgeries.

Practice Management

---

Telemedicine has become a critical part of care delivery during the COVID-19 pandemic, but many patients are unfamiliar with the format. The article offers five pieces of advice that physicians can offer to help their patients prepare for their first virtual visit. Patients will need a basic familiarity with video conferencing, and it is important that their internet connection is fast enough to do the call. Physicians should urge their patients to try the technology before their first appointment and download any needed apps before the visit. Telemedicine visits are typically about 20 percent shorter than in-person appointments.

Patients will want to maximize their time by preparing questions they have in advance of the appointment. Insurance coverage for telemedicine visits vary, so patients should contact the organization before their first telemedicine visit to double check what's covered under their plan. Telemedicine visits are subject to HIPAA and are private matters, so physicians should make sure their patients are aware and have a quiet, discreet space to take the call and use headphones if possible. Good lighting is also important for any visible concerns they may have. Ask them to wear clothing that is easy to move in so they are best able to participate in a physical exam. Patients should have a clear understanding of how to get in touch with their provider for follow-up care and how to get necessary prescriptions.


A recent retrospective study assessed whether differences in income between male and female physicians vary according to the sex composition of physician practices. It looked at 18,802 physician salaries from 9,848 group practices categorized according to proportion of male physicians. Among 11,490 non-surgical specialists, the absolute adjusted sex difference in annual income (men versus women) was $36,604 for practices with up to 50 percent of male physicians, compared with $91,669 for practices with at least 90 percent male physicians. Similar findings were observed among surgical specialists, with absolute adjusted sex difference in annual income of $46,503 for practices with up to 50 percent of male physicians, compared with $149,460 for practices with up to 50 percent of male physicians. Among primary care physicians, sex differences in income were not related to the proportion of male physicians in a practice.


Physician practice mergers can prove vital, but the businesses will most likely have to change in order to stay relevant and profitable. Certain traps to avoid include failing to focus the new practice in a way that harmoniously reflects both owners involved. It is critical that the owners communicate openly about their desires and establish early ownership percentages early on. Governance documents should clearly state which owner makes certain decisions. Other issues to settle before the merger include practice name, positions on the governance board and staff retention. It is also critical to conduct proper due diligence and check for any debts, judgments or potential judgments, payroll and other taxes, contracts with suppliers, employment contracts with staff and other obligations that may be incurred.

Health Policy and Reimbursement

---

During the pandemic, enrollment in Affordable Care Act (ACA) plans has been a boon for states launching their own health insurance marketplaces. A rise in enrollees will likely reduce per-person costs for insurers and lower premiums, particularly as more healthy people look to get covered, which could lead more insurers to the exchanges and increase competition in the ACA market, according to analysts. Insurers may be especially drawn to state-based exchanges since states typically spend more money on outreach and marketing and may combine their exchanges with reinsurance programs that lower premiums, as Pennsylvania has done. The US Department of Health and Human Services reported that almost a half-million people enrolled in the federal HealthCare.gov exchanges through May after losing their jobs, a 46 percent increase from the same time period last year. Twelve of the 13 existing state-based exchanges have held their own special enrollment periods for more people to get covered in the face of the public health crisis.


According to the latest enrollment figures released by the US Centers for Medicare and Medicaid Services, Medicaid enrollment was 72.3 million in April, up from 71.5 million in March and 71 million in February. The increase in March was the first enrollment uptick since March 2017. About half of the people enrolled in Medicaid are children. While the increase in people covered by Medicaid nationwide reversed a three-year decline, the growth in participation in the state-federal health insurance program for low-income people was less than many analysts predicted. Analysts suggest that people may not enroll because they have concerns about catching the coronavirus and are avoiding care, so they figure they don't need the coverage. However, program sign-ups are widely expected to accelerate through the summer, reflecting the higher number of unemployed.


The growth in telehealth services during the COVID-19 pandemic has led some healthcare providers and lawmakers to seek an extension of regulatory accommodations for telehealth services that were granted during the COVID-19 pandemic. However, health insurers want policymakers to manage concerns regarding its overutilization and to redefine healthcare provider state licensing requirements. Both Alex Azar, secretary of the US Department of Health and Human Services, and Seema Verma, administrator of the US Centers for Medicare and Medicaid Services, have also expressed their support in making the regulatory relief longer lasting, but it would require Congressional action. America's Health Insurance Plans says that to ensure continued growth in telehealth, policymakers must allow insurance providers to be able to design their benefits and offerings in accordance with the needs of their members. Insurers are also asking policymakers for flexibility in reimbursements and permission to use utilization management tools.

Medicine, Drugs and Devices

---

Researchers say there is growing evidence that masks help safeguard people who wear them by reducing the severity of symptoms or even preventing infection. Monica Gandhi, MD, MPH, an infectious disease physician at the University of California, San Francisco, and colleagues wrote in a paper that different types of masks "block virus to a different degree, but they all block the virus from getting in." Moreover, if any virus particles are able to infiltrate the mask, the disease might still be milder, according to the researchers, whose paper is set to be published in the Journal of General Internal Medicine. Based on animal experiments and observations of various events during the COVID-19 pandemic, they say people wearing face coverings will take in fewer coronavirus particles, which makes it easier for their immune systems to deal with the pathogen.

Tsion Firew, MD, an emergency physician at Columbia University who was not involved in the work, warns that the connections between masking and milder disease have not yet been proved as cause and effect. Still, the paper "reiterates what we say about masks. It's not just a selfless act," she asserts. Gandhi says the way for people to curb the pandemic is to assume they are infected, "even if you feel right as rain."


As US COVID-19 outbreaks continue to surge, a new government study shows that nearly 40 percent of people who have died with COVID-19 had diabetes. Among deaths of those under 65, half had the chronic condition. Jonathan Wortham, an epidemiologist at the Centers for Disease Control and Prevention who led the study, called the findings "extremely striking," with serious implications for those with diabetes and their loved ones. A separate Reuters survey of states found a similarly high rate of diabetes among people dying from COVID-19 in 12 states and the District of Columbia. Ten states, including California, Arizona and Michigan, said they weren't yet reporting diabetes and other underlying conditions, and the rest did not respond.

Keeping diabetes under control, among the best defenses against COVID-19, has become difficult as the pandemic disrupts medical care, exercise and healthy eating routines. The high price of insulin has also forced some people to keep working, risking virus exposure, to afford the essential medicine. Doctors warn that the coronavirus pandemic may indirectly lead to a spike in diabetes-related complications.


President Donald Trump signed four executive orders on July 24, one of which was about prescription drug importation. The others would direct drugmaker rebates straight to patients, provide insulin and EpiPens at steep discounts to low-income people and use lower international prices to pay for some Medicare drugs. However, consumers may not notice immediate changes, since the orders must be carried out by the federal bureaucracy and could face court challenges. Meanwhile, the House already passed legislation to tackle prescription drug costs by authorizing Medicare to negotiate lower prices with pharmaceutical companies.

Americans remain worried about drug costs, with nearly 9 in 10 saying in a recent Gallup-West Health poll that they're concerned the pharmaceutical industry will take advantage of the coronavirus pandemic to raise prices.