News From ACFAS

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After careful consideration of applicants to serve on the ACFAS Board of Directors, the Nominating Committee recommends the following four Fellows for three positions in the upcoming electronic election. The committee’s deliberations included written applications, volunteer histories, CVs, Open Payment data and telephone interviews.

• Christopher D. Lotufo, DPM, FACFAS
• Alan Ng, DPM, FACFAS
• Ryan T. Scott, DPM, FACFAS
• Matthew Williams, DPM, FACFAS

Two, three-year terms and one, two-year term will be filled by election. Candidate profiles and position statements will be posted at acfas.org/nominations on November 27. Eligible voters may cast one, two or three votes on their ballot. Regular member classes eligible to vote are Fellows, Associates, Emeritus and Life Members.

Online voting will be conducted December 6-22. All eligible voters will receive an email with special ID information and a link to the election website in advance. After logging in, members will first see the candidate biographies and position statements, followed by the actual ballot. Eligible voters without an email address will receive paper instructions on how to log into the election website and vote. There will be no paper ballots.

The 2019 Nominating Committee included ACFAS Fellows John S. Steinberg, DPM, FACFAS, Chair; Adam Budny, DPM, FACFAS; William J. Finn, DPM, FACFAS; Aksone Nouvong, DPM, FACFAS; Roland S. Ramdass, DPM, FACFAS; Christopher Reeves, DPM, FACFAS and Eric G. Walter, DPM, FACFAS. There is still time to volunteer to serve on a 2020 ACFAS committee, Clinical Consensus Statement panel or as a reviewer of Scientific Literature. ACFAS is looking for members who are leaders, thinkers, team players and hard workers to work with the College to shape the future of our profession.

To volunteer, visit acfas.org/volunteer. The application deadline is October 31, 2019.
Ask and you shall receive, Residents’ Day is back at ACFAS 2020! Join us on Tuesday, February 18 in San Antonio for another must-attend interactive seminar designed specifically for residents.

Spend the day with seasoned foot and ankle surgeons to hear their stories and experiences, get helpful tips on everything from job search and interview prep to practice types and managing difficult cases, participate in discussions and Q&A over lunch and network throughout the day.

You won’t want to miss the chance to get first-hand advice from these experienced surgeons, all eager to welcome residents to the College and profession. Registration information is coming soon, visit acfas.org/sanantonio for updates. Students and residents, are you trying to decide which practice type is a best fit for you? Also, are you interested in hearing insight on common malpractice issues and understanding the complex intersection of law and medicine? Mark your calendars for two complimentary webinars scheduled in November:

Don't Be an Outlaw: Learn to Wrangle Malpractice Mysteries
Thursday, November 7
8pm CST
Register Now

Practice Models: Which Model Fits You Best
Thursday, November 14
8pm CST
Register Now

Foot and Ankle Surgery

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The study uses finite element analysis to compare the mechanical efficacy of a locking compression plate (LCP) with traditional four-millimeter cancellous screws (CS) for transverse, oblique and vertical medial malleolar fractures. Three-dimensional models of the distal tibia were reconstructed from a computed tomography scan of a healthy young adult male. Conditions included three fracture lines at 30 degrees, 60 degrees and 90 degrees; two groups of fixation (LCP and CS); and three adduction loads of 300, 500 and 700 N applied to the medial malleolar joint surface. The proximal part of the tibia was fixed for all degrees of freedom. The LCP constructs were much more stiff than the CS constructs, especially in the 90-degree fractures, and the LCP had smaller fracture displacements than CS. The mean stress around the CS was higher than that in the LCP for 60-degree and 90-degree fractures, and medial bone stress increased and concentrated on cortical bone in LCP, while it concentrated on cancellous bone in CS. The results suggest that LCP could improve stability and prevent bone destruction in oblique and vertical medial malleolar fractures, while CS provides sufficient stability in transverse fractures.


A structural graft can be used to maintain correction and achieve union after anterior calcaneal lengthening osteotomy for treatment of flexible flatfoot. Polyaryletherktone cage has a healing rate similar to that of the current standard, autograft, as well as high stability and no donor-site morbidity, but it has only been documented for use in spine surgery. The study reviewed 13 patients with painful flatfeet after failure of conservative treatment who were treated by anterior calcaneal lengthening osteotomy using polyaryletherketone cage instead of bone graft. The patient cohort had six males and nine females, and the mean age at the time of surgery was 10.8 years. Nine patients had a unilateral procedure and three had a simultaneous bilateral. The paired t-test result was statistically significant in comparison of radiographic pre- and post-surgery measurements. All cases showed full union clinically and radiographically at last follow-ups, with no complications. The data suggest that polyaryletherketone cage may be used as a structural graft option for anterior calcaneal lengthening osteotomy.


This Level III case-control study illustrates the use of a modified subcapital metatarsal osteotomy (MSMO) in the treatment of hallux valgus (HV) recurrence. The article reports the clinical and radiological outcomes of 46 female and six male patients presenting with recurrent HV that were treated with MSMO between May 2010 and November 2015, with a mean follow-up time of 2.5 years. The results indicate that the minimally-invasive MSMO is a reliable technique for restoring anatomical alignment and improving patient outcomes in recurrent cases of HV. Postoperative radiographic assignments show significant improvement of the HV angle, the intermetatarsal angle and the position of the tibial sesamoid. The distal metatarsal articular angle was improved, though assessment may be affected by previous operations performed on the first metatarsophalangeal joint. The statistical analysis shows significant improvement in the postoperative American Orthopaedic Foot and Ankle Society Hallux Metatarsophalangeal-Interphalangeal Scale parameters.

Practice Management

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DNA sequencing is creating vast amounts of data that promise to unlock the secrets of disease. But the information is being collected faster than the medical world can interpret what it all means. That is raising a question for doctors and scientists who perform the scans: How much should they tell patients? The answer, often, is not much. Many clinics and studies will return only a few dozen results that researchers have deemed “medically actionable”—meaning they reveal genetic causes for conditions that can be treated.

Doctors often don't analyze and return other results because the risk of a trait isn't well-understood or because there is no treatment. Not everyone with disease-causing variants will end up with a related condition, because of other genetic and environmental factors. The risk may be low for some. If told, some patients could seek unnecessary or harmful care or unduly worry about a disease they may not get. Some doctors, however, say it is paternalistic to withhold information if patients want it. Several studies have suggested that most patients want to learn their own genetic results.


Ransomware attacks have crippled small healthcare systems and medical providers, and they are only becoming more common as time goes on. Healthcare systems and medical providers are attractive targets for hackers because they typically hold a plethora of very valuable medical and billing information, but often do not have the money or resources needed to build up strong cyber-defenses. If hackers successfully steal the data, they can sell it for insurance fraud purposes or otherwise use it to extort the victim company or system into paying a ransom to get it back. And when an attack hits a hospital, healthcare system or medical provider, routine procedures can be disrupted for weeks or even longer.


As part of its efforts to reduce the administrative burden carried by physicians, Massachusetts General Hospital (Mass. General) has expanded the use of voice-recognition software to allow doctors to speak instead of type their notes. In addition to the nearly 200 scribes working in its clinics, Massachusetts General Hospital has introduced a virtual scribe program whereby India-based doctors do documentation for Mass. General physicians. Physician burnout has plagued hospitals around the country, and the issue became especially prominent at Mass. General after the 2016 rollout of a complex new electronic health records system.

Proponents of virtual scribes say that the remote workers actually take better notes than local doctors because they can type while they listen instead of relying on memory to recall details. IKS Health, which makes the virtual scribe program Scribble, reports that its program has similar costs to conventional scribe roles, which tend to pay slightly above minimum wage. All of the virtual scribes have medical degrees and are trained to take notes like US doctors, and the majority of patients provide the consent needed for physicians to record their conversations.

Health Policy and Reimbursement

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The U.S. Centers for Medicare and Medicaid Services (CMS) released a proposed rule to remove what they describe as unintended hurdles to coordination of patient care due to outdated rules about clinicians' financial relationships. The measure would create new exceptions to the Stark Law, which was intended to stop physicians from profiting at the expense of patients at a time when there was little challenge to Medicare's fee-for-service model. The proposed rule would make it easier for firms to donate software that protects electronic health records from hacking. The Department of Health and Human Services issued a companion proposed rule that examines federal antikickback laws, which date to 1972, also emphasizing the need for special carve-out for cybersecurity.


A study published online in JAMA reviewed previous literature and estimated that the U.S. healthcare system wastes between $760 billion to $935 billion, or about 25 percent of total healthcare spending. Potential savings from interventions that reduce waste ranged from $191 billion to $282 billion. Computations focused on six domains of cost waste: failure of care delivery, failure of care coordination, overtreatment or low-value care, pricing failure, fraud and abuse and administrative complexity. The most costly domains were administrative complexity, which cost $265.6 billion, and pricing failure, which cost $230.7 to $240.5 billion. The highest potential savings were calculated for pricing failure and failure of care delivery.

Medicine, Drugs and Devices

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A study by Prime Therapeutics found that the number of patients who need costly specialty drugs is sharply increasing. The study analyzed data on over 17 million commercially-insured patients with at least one eligible month in each year between 2016 and 2018. It finds that costly specialty drugs now make up more than half of the total drug market, and in 2018, 4,869 people were identified as "super spenders" with drug costs totaling more than $250,000 per year. The number of super spenders increased by 63 percent from 2016 to 2018 and led to an additional $800 million in additional drug costs, and the number of patients who spent more than $750,000 per year on drug costs increased by 38 percent. Total drug costs for the group increased from $297 million in 2016 to $417 million in 2018.


Companies like CirrusMD offer chat diagnosis, wherein doctors remotely connect with and treat care recipients by text messaging. Such services typically cover injuries or minor illnesses normally managed by a doctor's office or clinic. Their business is expanding due to a campaign to improve care access, keep people healthy and limit costly visits to the emergency room. However, some physicians are concerned about the quality of care provided by such services, given that doctors do not see recipients and might have a limited medical history to consider before planning treatment.

Message-based care providers claim they take measures to ensure safety and recommend in-person doctor visits when necessary. They also say a comprehensive medical history is not always essential, while doctors do not always require vital signs like temperature and blood pressure, but can coach recipients through taking them if necessary. Physicians also can elect to hold video or phone conversations when needed.


The National Library of Medicine (NLM) is working on analysis tools to facilitate research use of HL7's Fast Healthcare Interoperability Resources (FHIR) standard for electronic health record (EHR) systems. FHIR is a standardized method for transmitting data between EHR systems through an API, or a specified set of protocols that establish ground rules by which systems communicate directly with each other. The NLM project is undertaken in accordance with a National Institutes of Health (NIH) notice from July, which directed NIH-funded researchers to explore the use of the FHIR standard to facilitate the sharing of research data.

The NIH-funded NLM has recently broadened its digital information services to leverage EHRs in addition to journal articles and databases. For example, NLM offers MedlinePlus Connect, a free service that lets healthcare organizations and health IT vendors to link patient portals and EHR systems to medical information resource MedlinePlus. The service responds to requests for information based on diagnosis, medication and laboratory codes, providing relevant health information in response to code-based requests submitted by an EHR, patient portal or other system.


A new patient survey from insurance giant UnitedHealth Group finds that more patients are using technology to comparison-shop their healthcare. Thirty-seven percent of respondents used the internet to shop around for healthcare in the past year, 39 percent of whom used that information to change their healthcare facility or physician. This is a sharp increase from 2012, when another UnitedHealth Group survey indicated that only 14 percent of respondents had used technology in these decisions. Fifty percent of the comparison shoppers in the 2019 survey were millennials, and 80 percent told surveyors that using technology was somewhat or very helpful in their choice. In terms of care, 45 percent of respondents said they would be interested in their doctors using artificial intelligence (AI) to help with treatment decisions. Forty-six percent of these patients said they believed AI may lead to a more accurate diagnosis and 31 percent said it might reduce human error on the part of the physician.