News From ACFAS

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Be an ACFAS Leader. Help make a difference and advance the profession by volunteering to serve on a 2022 ACFAS committee, Clinical Consensus Statement panel or as a scientific literature reviewer where you’ll have an active role in helping to shape the future of our profession.

Applications are due October 31. Visit acfas.org/Volunteer to volunteer today. Ramp up your research skills tomorrow with the next installment of ACFAS Virtual Journal Club.

ACFAS Virtual Journal Club | Thursday, October 21, 7pm CT
This month’s installment features Options for Lateral Ankle Reconstruction hosted by the South Central Pennsylvania Reconstructive Foot and Ankle Fellowship in Lancaster, PA.

Visit acfas.org/JournalClub to register for this week’s Virtual Journal Club now. If you’re having trouble finding just the right person to hire for your practice, sign up to be a part of ACFAS’ Virtual Career Fair on November 3, 5-8pm ET.

This new career fair gives employers the opportunity to connect with the best and brightest foot and ankle surgeons from the comfort of your own home or office! Employers can sign up to host a virtual employer booth to post open positions or access the CV Library filled with interested candidates. Plus, there’s opportunities to chat in real time with potential applicants or request a video chat on the spot!

Limited spots are available! Find out more or sign up today.

Foot and Ankle Surgery

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A study investigated plantar pressure distribution between lateral wedge insoles (LWI), standalone insoles and medial arch supported-LWI to yield insights for informing insole prescription, with concomitant foot symptoms considered. In-shoe plantar pressure was measured among 40 healthy individuals as they walked with LWI, with or without medial arch support and a flat control insole condition. Pressure data from the plantar surface of the foot was split among medial/lateral rearfoot, midfoot, medial/central/lateral forefoot and hallux. On a regional basis, medial rearfoot and forefoot pressure were reduced by all wedged insoles, with the variable-stiffness supported-wedge exhibiting greater reductions than the standalone wedge. Lateral rearfoot and forefoot pressure were reduced by both supported-LWI, but were not changed by the standalone wedge. The standalone wedge maintained pressure in the midfoot but reduced regional contact area, while both supported-LWI increased midfoot pressure and contact area. All LWI increased the medial-lateral pressure index, signaling a lateral shift in plantar pressure distribution throughout the weightbearing phase of gait. Comfort ratings did not differ significantly between insole conditions.


A retrospective cohort study investigated risk factors for longer total hospitalization duration in elderly patients with surgically treated fragility fractures. Included were 97 patients 70 years and older with a fragility fracture treated surgically between 2011 and 2019 in a level 1 and 2 trauma center. Average patient age of was 78.27 years, and 71 patients (73.20 percent) were women. Ten fractures (10.30 percent) were classified as open and 49 (50.50 percent) as a luxation type fracture. Fifty-nine patients (60.80 percent) were hospitalized following emergency department admission, while external fixation was performed in 34 patients (35.10 percent) and served as bridge to definitive fixation in 29 (85.30 percent). Average total hospital stay of all patients was 7.04 days. Multivariate regression analysis showed external fixation and the postoperative discharge destination were independently associated with prolonged hospitalization.


Researchers conducted a study that quantifies gait changes associated with operatively-confirmed peroneal tendon tears. Sixty-five patients with unilateral peroneal tendon tears were prospectively evaluated using preoperative three-dimensional multisegment gait analysis of both limbs. Data were analyzed according to pattern/severity of tears, as confirmed surgically: peroneus brevis tears, reparable (PBR); peroneus brevis tears, irreparable (PBI); peroneus longus tears, irreparable (PLI) and concomitant irreparable tears of both tendons (PBI+PLI). Twelve patients had the PBR pattern, 37 PBI, 10 PLI and six PBI+PLI. Compared with the contralateral, nonpathologic extremities, limbs with peroneal tears had diminished ankle sagittal motion, ankle/hindfoot axial rotation, sagittal moment and sagittal power. The most severe tear patterns had the greatest derangements in multiple parameters of gait. The researchers say this is the first study to demonstrate diminished biomechanical function in patients with peroneal tendon tears. In vivo three-dimensional gait analysis found significant changes in hindfoot motion, ankle motion and ankle power. Impairments were related to the pattern and severity of the tears and demonstrated a strong association of peroneal tendon tears with diminished ankle plantarflexion strength.

Practice Management

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One in five US physicians has considered leaving their current job to pursue nonclinical careers, according to the Medscape Physician Nonclinical Careers Report 2021. The poll of more than 2,500 physicians across the country determined that 58 percent of those wanting to change career paths said they planned to do so within three years. Meanwhile, 80 percent of respondents looking for a career change are actively investigating other options, with 53 percent searching online. Education was the top field surveyed physicians are looking to enter at 42 percent. Thirty-four percent listed general burnout as the top reason for switching, while 7 percent cited burnout from the pandemic. Moreover, 20 percent said they wanted to work fewer hours.


Medical practices can start implementing strategies to mitigate their tax burden, with one of the most important being proper entity selection. This is determined by who the owners of the practice will be and how the profit will be taxed in the practice. Sole proprietorship often appeals to professionals because it is simple and inexpensive to set up and maintain. However, it creates unlimited individual risk for the practice owner and tends to be audited more frequently by the IRS than partnerships, S-corporations or C-corporations. Meanwhile, a partnership's tax return functions as an information return, and the income and losses pass through the entity and into the owners' personal tax returns. Liability issues still exist with a partnership unless it is a limited liability company, whose protections do not apply to physicians. S-corporations are also pass-through entities, with Social Security and Medicare taxes assessed, while any profit above one's salary is considered a distribution and not subject to those taxes.

A C-corporation is a standalone entity that shields against most practice liabilities, but not malpractice, while profits are taxed at the entity level. Contributing to a retirement plan is the easiest and most direct route for reducing taxes, while employing family members can shift income from a higher to a lower tax bracket and create a deduction of their wages via the practice. A gift-leaseback arrangement can replace the current salary of a family member, provided a proper appraisal of the equipment is made and a rental agreement is in place with the family member.


Derek Kosiorek with the Medical Group Management Association offers tips on building the ideal practice website to interest potential patients. He recommends that practices always use their own domain names and update their sites constantly. The site layout should be basic and not overthought, and investing in a content management system (CMS) is advantageous, as it is simple and easy to use. Kosiorek also says the person given the CMS admin password must be trustworthy, while search engine optimization is easy enough to make an outside firm's services unnecessary. Website design should also be responsive to accommodate visitors' various modes of access, and big pictures and background colors are to be avoided. Finally, the website should serve as the practice's homepage for all of its computers.

Health Policy and Reimbursement

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The US Centers for Medicare & Medicaid Services' (CMS) 2022 rankings aim to help beneficiaries compare Medicare Advantage (MA) and Medicare Part D prescription drug plans ahead of Medicare open enrollment, which runs from Oct. 15 to Dec. 7. The agency adjusted the ratings to reflect the impact of the COVID-19 pandemic, although it said the uptick in plans scoring four or more stars also mirrors improvements made on several measures CMS considers. The agency explained that in view of the pandemic, it "wanted plans to have some degree of certainty related to Star Ratings program requirements," and to ensure plans focused on providing care for beneficiaries.


A Kaiser Family Foundation study found 71 percent of Medicare beneficiaries do not explore their coverage options during open enrollment, and experts caution against this because specifics of health plans change from year to year. In all, 48.5 million beneficiaries have prescription drug coverage through either a Medicare Advantage Plan or a standalone plan. Kaiser's analysis of 2019 coverage choices found 68 percent of Advantage Plan beneficiaries said they did not do any comparisons, versus 73 percent of original Medicare enrollees. Advantage Plan changes could include modifications to monthly premiums, copays, deductibles, coinsurance or the maximum out-of-pocket limit. Drug coverage could also change, along with doctors, hospitals and other providers that are considered in-network for the Advantage Plan. Beneficiaries who discover after fall enrollment that their choice of Advantage Plan is a bad fit can change their coverage between Jan. 1 and March 31, but they would be unable to switch from their standalone Part D plan to another during that window.

Medicine, Drugs and Devices

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New research published in JAMA Network Open indicates that insulin glargine and other analogs dominate insulin use in the United States, alongside pen devices for delivery. The findings were derived from data from the Health National Disease and Therapeutic Index, which includes diagnostic and prescribing information on patients treated by office-based physicians. There were a total of 27,860,691 insulin treatment visits for type 2 diabetes in 2016-20, of which long-acting analog insulins accounted for approximately 21.2 percent of visits in 2016 and approximately 16.5 percent in 2020. Intermediate- and short-acting human insulins accounted for just 3.7 percent of visits in 2016 and 2.6 percent in 2020. Together, the long- and short-acting analogs comprised 92.7 percent of visits in 2016 and 86.3 percent in 2020, while the human insulins accounted for just 7.3 percent of visits in 2016 and 5.5 percent in 2020. The biosimilar analog insulins—glargine and lispro—first appeared in the database in 2017, representing 2.6 percent of visits that year and 8.2 percent by 2020. The proportion of treatment visits for insulin vials/syringes declined from 63.9 percent in 2016 to 41.1 percent in 2020, while visits for insulin pens increased from 36.1 percent to 58.7 percent.


The US Food and Drug Administration (FDA) Center for Devices and Radiological Health issued best practices for communicating medical device vulnerabilities to patients and caregivers. The agency emphasized that organizations devise a communications strategy on medical device security and take steps to ensure that the messaging is clearly interpretable, explicitly cites risks and acknowledges the unknown. "Whenever feasible, communicate with patients and caregivers as early as possible, especially if the cybersecurity vulnerability may present a risk to patient safety," the guidelines recommended. "Early access to serious cybersecurity vulnerability information may provide assurance to patients and empower them to take early action to avoid any potentially harmful consequences to their health. Furthermore, early access to this information may also help build trust with patients and the public."

FDA also cited the importance of adding a call to action in all communications to patients and caregivers. Organizations should train patients on how they can mitigate risks themselves, supplemented by clear and concise directions. The agency also advised embedding search engine optimization strategies into communications so patients can easily find reputable information about their medical devices.


A new Kaiser Family Foundation poll reveals that 83 percent of Americans support allowing the federal government to negotiate lower drug prices, both for Medicare and private insurance plans. Respondents were presented with arguments both in favor of the proposal and against. There was a small increase in the percentage of respondents saying they "somewhat" favored the policy after hearing the arguments, rather than "strongly" favoring it. After hearing both assertions, 71 percent of Republicans continued favoring the policy. The findings come as Democrats seeks to incorporate a version of the drug pricing policy in President Biden's extensive "Build Back Better" package now moving through Congress. That proposal will likely feature a cap on drug prices as well as allowing negotiations. However, some moderate Democrats have expressed concerns, and lawmakers are considering revisions to the legislation. The poll also found that one in five US adults aged 65 years and over said it is very or somewhat difficult for them to afford their prescription medications.