News From ACFAS

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Profiles and position statements for the four candidates recommended by the Nominating Committee to fill two vacancies on the ACFAS Board of Directors are now available at acfas.org/nominations: George T. Liu, DPM, FACFAS (Incumbent); Shane M. Hollawell, DPM, FACFAS; Andrew J. Meyr, DPM, FACFAS; and Gregory Still, DPM, FACFAS.

Online voting will be conducted December 11-28, 2020. Watch your email and ACFAS publications for more information on how to vote. ACFAS and the Council for Journal Management are excited to announce the launch of our new, open access journal, Foot & Ankle Surgery: Techniques, Reports & Cases (FASTRAC).

A companion journal to JFAS, FASTRAC led by Editor-in-Chief Thomas S. Roukis, DPM, PhD, FACFAS will be the home of case reports currently submitted to JFAS and other brief communications such as techniques videos and is intended to be a more rapid publication of papers that allows ACFAS members and other foot and ankle surgeons around the world to stay up-to-date on the best clinical practices. FASTRAC will give you access to practice-based evidence via case reports and articles on novel techniques to advance clinical research and daily clinical practice.

Authors can expect a more streamlined processes as articles can be directly submitted to the journal, and any not accepted for JFAS deemed more suitable for FASTRAC will be transferred. Articles will be published under a Creative Commons license allowing contents to be accessed for free anywhere in the world.

FASTRAC begins accepting submissions in early 2021! Watch ACFAS publications and your email for more information as they develop.
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Foot and Ankle Surgery

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The study investigated muscle strength deficit in mechanical ankle instability (MAI) patients, with a view to proposing a more targeted muscle strength training strategy. A total of 220 MAI patients with confirmed initial lateral ankle ligament rupture and a postinjury duration of more than six months were included. All patients underwent a Biodex isokinetic examination of the ankle joints of both the affected and unaffected sides. Then, the associations between the limb symmetry index (LSI) and various patient traits and conditions were analyzed. There was significantly weaker muscle strength on the affected side than on the unaffected side in all directions. The LSI in plantar flexion was significantly lower than that in dorsiflexion at 60 degrees. A lower LSI in eversion was significantly correlated with female sex and isolated anterior talofibular ligament injury.


The study examined the effects of individually designed insole in pes planus treatment. Designed insoles was adjusted according to the sole of each participant with pes planus in order to improve their physical parameters. A total of 34 participants with pes planus participated in the study. It was determined that individually designed insoles reduced body weight and BMI, made positive improvements in 30-meter speed, vertical jump and 12-minute Cooper scores and significant decrease in Visual Analog Scale (VAS) scores. In conclusion, individually designed insoles appear to help normalize the forces acting on the foot and improve the physical performance parameters of individuals with pes planus.


The study investigated the rotational effect of scarf osteotomy with trans-articular lateral release on hallux valgus correction in 28 consecutive patients (30 feet). The first intermetatarsal angle (IMA), hallux valgus angle (HVA), round-shaped lateral edge of the first metatarsal head (R sign) and sesamoid rotation angle (SRA) were recorded prior to and three months after the surgery. The rotation of the capital fragment of the first metatarsal was termed the capital rotation angle (CRA) and was measured intraoperatively after the completion of scarf osteotomy. The IMA, HVA and SRA were significantly reduced. The mean CRA was not significantly correlated with the reduction of IMA and SRA, nor was it significantly correlated with IMA pre-operatively and post-operatively or the reduction of SRA and IMA. The R sign was positive in 40 percent of the feet preoperatively compared to 13.3 perecent postoperatively.

Practice Management

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Thousands of medical practices have closed during the pandemic, according to a July survey of 3,500 doctors by the Physicians Foundation. About 8 percent of the doctors reported closing their offices in recent months, which could equal some 16,000 practices, while another 4 percent said they planned to shutter within the next year. Other doctors and nurses are retiring early or leaving their jobs due to concern for their own health, family obligations or burnout from the stresses of working during a pandemic. An analysis from the Larry A. Green Center found that nearly a fifth of primary care clinicians surveyed in September say someone in their practice plans to retire early or has already retired because of Covid-19, and 15 percent say someone has left or plans to leave the practice. About half of the physicians surveyed said their mental exhaustion was at an all-time high, and about 7 percent said they were not sure they could remain open past December without financial help. Still, the Paycheck Protection Program has helped many medical practices stay afloat, and some family offices are seeing higher volumes again.


As telehealth becomes ever more prominent, physician workflows and clinical spaces must be made to accomodate both in-person and virtual visits. One way to do this is to use mobile workstations to support accessible, flexible care and streamlined workflows. Many mobile workstations can be customized, allowing health systems to optimize the platform for their specific telehealth program. Mobile workstations can also easily incorporate advanced technology such as cameras, digital instruments and expanded monitors. Practices should also try to define a dedicated zone workflow for exam rooms where virtual visits can be effectively conducted, which may require a redesign of the space. This workflow design establishes two distinct patient care zones within the exam room, providing clear separation between the care zone for in-person caregiver interaction and the private zone where telehealth visits can be conducted. This virtual visit zone should be designed to enhance the experience for the patient, ensuring quality lighting and audio on the call.

Health Policy and Reimbursement

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Like many things in 2020, employee benefits and perks are being reshaped by the coronavirus pandemic. During open enrollment season, many companies are expanding voluntary medical benefits for their employees, including hospital indemnity plans, coverage for couples therapy and access to prepaid legal plans for workers concerned about getting their end-of-life affairs in order. The Business Group on Health found that 53 percent of its members plan to expand virtual care options, while 36 percent plan to expand access to mental health services. Other voluntary benefits growing in popularity this year include identity theft protection. In addition to expanding the benefits available to workers, some companies are also offering new perks.


The level of competition in the commercial health insurance market nationwide has declined since 2010, when the Affordable Care Act (ACA) was enacted, according to a report by the US Government Accountability Office (GAO). GAO analysts examined the period from 2011 through 2018 for all 50 states and the District of Columbia. They defined a market as being highly concentrated if the top three issuers in the market accounted for 80 percent or more of market enrollment. In the individual major medical insurance market, 33 of the 51 jurisdictions studied had highly concentrated markets in 2011, rising to 41 in 2014, when the ACA exchange market emerged. The number of highly concentrated markets decreased to 37 in 2015 and 2016, rising to 46 in 2018. Similarly, the number of jurisdictions with highly concentrated small-group major medical insurance markets increased to 46 in 2018 from 36 in 2011.


A proposed rule to end rebates that drugmakers give to middlemen in Medicare is awaiting approval and a final rule could be imminent. The Trump administration has said the rule would lower the prices consumers pay for prescription drugs. An earlier version of the rule was withdrawn in 2019 because some White House advisers raised concerns that it could increase Medicare premiums. In July, Trump signed an executive order that revived the rule and added a requirement that it not raise premiums or increase federal spending. Ending the annual rebates would spare drug companies from paying billions of dollars to middlemen in Medicare. Health plans had fought against the proposal because they would then have to cover higher drug costs. The rule was revised because of the requirements on premiums imposed by the executive order.

Medicine, Drugs and Devices

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Amazon is moving into the drug-delivery business. With the launch of Amazon Pharmacy, the company hopes to gain a foothold in the US online prescription ordering market, which has been sluggish but could pick up as the COVID-19 pandemic finds more people staying at home. The service could also get a big boost from its vast Prime loyalty customer base, who will receive up to an 80 percent discount on generic drugs and as much as 40 percent off brand medications when they pay without insurance. If members prefer in-person shopping over two-day delivery, they can still enjoy the discounts on non-insurance purchases at more than 50,000 physical pharmacies, including those operated by competitors. Across the board, Amazon Pharmacy will let customers comparison-shop, toggling at checkout between the cost with co-pay and the non-insured price. The online store is available nationwide but is not yet available in five states: Illinois, Minnesota, Louisiana, Kentucky and Hawaii.


The US Centers for Disease Control and Prevention (CDC) has broadened the US Diabetes Surveillance System by adding a new social determinants of health (SDOH) module to better identify the nation's under-resourced areas and evaluate the potential effect of health disparities related to diabetes burden and risk factors. The revised system now merges diabetes data with 15 social vulnerability variables. Public health professionals and researchers can use the new SDOH module to more thoroughly examine factors potentially affecting people's ability to successfully manage diabetes and prevent type two diabetes.


Patients in New York who rely on opioid analgesics to manage chronic pain say they have been affected by the state's decision in July 2019 to enforce an excise tax on many opioids. The goal of the tax was to penalize drugmakers for their role in the opioid epidemic and to generate funding for treatment programs. To avoid paying the tax, however, many manufacturers and wholesalers stopped selling opioids in the state. Instead of the anticipated $100 million, the tax generated less than $30 million in revenue, according to two lawmakers. None of that money was allocated for substance abuse programs, they said. The tax follows efforts by federal and New York state officials to curb the use of prescription opioids, whose supply had already been pared down.