News From ACFAS

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Register now for the next webinar in the Forefoot Complications Series—Menacing Conditions—How to Make them Nice. This installment in the Forefoot Complications Webinar series gives an in-depth look at malunions of the foot requiring a surgical solution and case presentations from the faculty panelists.

Wednesday, October 28
Menacing Conditions—How to Make Them Nice
8pm CST | CME Hour: 1 Credit
Fees: Member $20 | Non-Member $30

Register today and build your bundle by picking any three available (live or recorded) webinars for the price of two! Visit acfas.org/OnDemand to register for the webinar and to see all upcoming e-learning opportunities. Fall is upon us, which means we have a new issue of FootNotes with more seasonal tips to help keep your patients’ feet and ankles healthy! This issue features:

• Finding the best shoes for kids to wear in school, and even tips for keeping them safe while e-learning at home due to COVID-19
• Elective surgeries and why it’s important not to push off treatment any longer
• A popular search topic all year—heel pain—and common types of heel pain and when it could mean a bigger issue

Customize this issue by adding your practice contact information to the second page to maximize your reach with current and potential patients. Distribute copies in your office, post the issue on your practice website and share it on your social media accounts.

Visit acfas.org/marketing to get the latest issue and check out all the other ways you can market your practice now! The monthly ACFAS Virtual Journal Club series is back with more sessions designed to teach the A to Zs of research! We have a great line up this year starting Tuesday, November 17.

Join the Palo Alto Foundation Medical Group Fellowship for a literature review on Osteochondritis Dissecans (OCD) hosted by Elizabeth Ansert, DPM, MBA, MA and presented by Amol Saxena, DPM, FACFAS and Ryan Allen, DPM.

The ACFAS Virtual Journal Club is open to all students and residents and will review noteworthy articles on pertinent topics of research. Most events will be the Third Thursday of each month, unless otherwise specified.

Visit acfas.org/JournalClub for more information and for registration links for the 2020-2021 lineup.

Foot and Ankle Surgery

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The study investigated the literature to evaluate the known pre- and postoperative biomechanical changes of the ankle after anatomic lateral ligament repair in patients suffering from chronic ankle instability. In this systematic review, studies published till January 2020 were identified by using synonyms for “kinetic outcomes," "kinematic outcomes," “Broström procedure" and “lateral ligament repair”. Included studies reported on pre- and postoperative kinematic and/or kinetic data. Twelve articles, including 496 patients treated with anatomic lateral ligament repair, were selected for critical appraisal. Following surgery, both pre-operative talar tilt and anterior talar translation were reduced similarly to the values found in the uninjured contralateral side. However, 10.5 percent of patients showed a decrease in ankle range of motion after the surgery. Despite the use of these various techniques, there were no identifiable differences in biomechanical post-operative outcomes.


The study sought to determine differences in Achilles tendon stiffness in people with gout compared to controls (non-gout). A cross sectional study comparing 24 people with gout and 26 age/sex-matched controls. Clinical and demographic data were collated, and US imaging used to determine tendon thickness, presence of gouty tophi and/or aggregates and levels of angiogenesis. Ten shear wave elastography (SWE) measures were taken along the center of a longitudinal section of the mid-portion of each Achilles tendon. A small proportion of those with gout presented with intra-tendon aggregates and/or intra-tendon tophi in one or both tendons. There was no statistically significant difference in tendon thickness between groups. Neo-vascularity was present in a third of gout participants. SWE findings demonstrated significantly reduced tendon stiffness in those with gout compared to controls. No relationship between the presence of tophi and SWE values were detected.


The study investigated the incidence of surgical site infection (SSI) in elective foot and ankle surgeries and identify the associated risk factors. This was designed as a retrospective study, including a total of 1201 patients who underwent 1259 elective surgery of foot and ankle between July 2015 and June 2018. Out of the patients included, 26 (2.1 percent) had an SSI, representing an incidence rate of 1.3 percent for superficial SSI and 0.8 percent for deep SSI, respectively. The results for organism culture showed Pseudomonas aeruginosa in seven cases, methicillin-resistant Staphylococcus aureus in six cases, methicillin-susceptible Staphylococcus aureus in five cases, methicillin-resistant coagulase-negative Staphylococci in two cases, Escherichia coli in two cases and Proteus mirabilis in one case. Five factors were identified to be independently associated with SSI: prolonged preoperative stay, allograft or bone substitute, elevated fasting blood glucose level, lower albumin level and abnormal neutrophil count.

Practice Management

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In light of the ongoing pandemic and resulting public health emergency, the US Centers for Medicare and Medicaid Services (CMS) suspended most audits on March 30. It has since resumed program integrity audits effective August 3. CMS recognizes that staffing and resources to respond to audits may be limited. Providers may contact Recovery Audit Contractors (RAC) to explain any COVID-19 related hardships they are experiencing that may impact response time. On August 3, CMS published five new RAC focus areas: ambulance services, hospital inpatient, hospital outpatient, ambulatory surgical centers and professional services. Medical records requests and overpayment demand letters will likely resume soon. The rules applicable to telehealth, supervision, inpatient rehabilitation facilities and nursing homes changed rapidly at the onset of the pandemic. This increased the likelihood of audit errors, misapplication of rules and application of rules and regulations to inapplicable dates of service.


Many physician-owners and practice executives assume staff is a cost they should always look to minimize, but this is not the case. Employees are essential to generating revenue, and team expenses should be considered an investment, not just a cost. any practices we’ve worked with are more troubled by front desk staff having occasional downtime than by what might not get done timely when staff are overloaded. In addition, practices that focus on minimizing staff may leave themselves vulnerable to spikes in demand, the exit of an employee or an illness that sweeps through the office. If employees feel overly stressed by their workload, practices will likely have higher turnover, and the costs of it can quickly exceed the profitability gains from cutting staff.

Health Policy and Reimbursement

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A report by the Georgetown Center for Children and Families reveals that the number of children without health insurance rose by 320,000 last year to a total of nearly 4.4 million. However, nationwide enrollment in Medicaid and the Children's Health Insurance Program (CHIP) has increased, aided by temporary policies to prevent families from losing coverage during the pandemic. As a result, more current estimates for uninsured rates among children will take time. The report found that the uninsured rate in 2019 for children living in states that did not expand Medicaid was 8.1 percent, almost double the rate (4.2 percent) in states that did expand. Overall, Medicaid and CHIP cover roughly 36 million children, nearly half the total number of children nationwide. The emergency funding bill that Congress passed in the spring bars states from terminating people's Medicaid coverage or tightening eligibility rules during the public health crisis.


According to the Medicare Payment Advisory Commission, of the 400 Medicare Advantage plans for 2021 with prescription drug coverage that received a rating, roughly 49 percent earned four stars or higher on a scale of one to five stars, with five being the highest. For 2020 plans, 52 percent scored four stars or more. The average star rating across all rated plans weighted by enrollment was 4.06, compared with 4.16 for 2020 plans. About 206 plans received 3.5 stars or less. Plans that score four stars or more receive a 5 percent increase to their benchmark, and those extra dollars can be used to fund extra benefits for seniors, though it's not required. Just 17 percent of enrollees in prescription drug plans are in contracts with four or more stars. Another 81 percent are in plans with 3.5 stars or higher.

Medicine, Drugs and Devices

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US Centers for Disease Control and Prevention (CDC) officials announced what they called a "national action plan" to fight antibiotic-resistant infections, which have been linked to an estimated 35,000 deaths across the United States annually. By 2025, the CDC aims is to reduce the prevalence of healthcare-associated antibiotic-resistant infections by 20 percent and community-acquired antibiotic-resistant infections by 10 percent. Domestically, the initiative will support investments in state and local health departments across the country, providing an average of $2.5 million per agency to "detect, contain and prevent antibiotic-resistant infections."


The US Food and Drug Administration's (FDA) Office of Generic Drugs released an updated Manual of Policies and Procedures (MAPP), which guides how applicants can petition FDA to submit an abbreviated new drug application (ANDA). Pharmaceutical companies submit ANDAs if a generic drug differs from a reference listed drug (RLD) in dosage form or strength or in its route of administration, as per Section 505(j)(2)(C) of the Federal Food, Drug, & Cosmetic Act. That legislation also applies to situations when a drugmaker seeks to submit an ANDA for a fixed-combination drug that has a single active ingredient that differs from the RLD. The MAPP states that FDA will approve a suitability petition under these criteria unless one of three circumstances is present.