News From ACFAS

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Last Friday, December 11, ACFAS eligible voting members received an email from the College's independent election firm with a unique link to the 2021 Board of Directors Election website. If you are a Fellow, Associate, or Emeritus member, please take a few minutes to cast your vote for your elected leadership. Your vote is important to advancing our profession and surgical specialty.

If you have not yet voted, two more reminder emails with your unique link will be sent to you before the election closes on Monday, December 28, 2020. If your email system blocked the test email from our election company, your voting instructions were sent by US mail. Be a part of an annual tradition that captures the very best in foot and ankle medical research. Present your latest discoveries by submitting a poster abstract for this year's poster competition at ACFAS 2021 in Las Vegas. Every year, the poster competition presents the very best and latest research in Case Study, Scientific and Student Club categories.

Poster abstracts must be submitted to ACFAS by January 13, 2021 to be eligible for review. Submission guidelines and criteria are now available at acfas.org/postersubmission. Another issue of FootNotes is here with more seasonal tips to help keep your patients' feet and ankles healthy all winter long! This issue features:

• Winter tips for those living with diabetes to keep their feet safe and injury free
• How best to deal with your child's ingrown toenails at home and what not to do
• Ways to make sure you're getting enough vitamin D to avoid stress fractures this winter

As always, you can customize this issue by adding your practice contact information to the second page for maximum reach with current and potential patients. Hand out copies in your office, post the issue on your practice website and share it on your social media accounts.

Get the latest issue now! Visit acfas.org/marketing to download it and to see other ways you can market your practice. In recent years, research has led to a relative change in the way that many surgeons view acute Achilles tendon rupture. To fully evaluate these trends and care for an acute Achilles tendon rupture, ACFAS has released a Clinical Consensus Statement (CCS) on Acute Achilles Tendon Pathology, which will appear in the January/February issue of The Journal of Foot & Ankle Surgery and is available online at jfas.org and acfas.org/CCS.

The statement is the latest addition to the College's library of CCSs, which provide physicians with a recommended approach to the treatment of specific conditions and pathologies. This statement can be used by practitioners to discuss treatment options with their patients and is also helpful to understand current trends in care for acute Achilles tendon rupture.

Foot and Ankle Surgery

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The study investigated tendon stiffness and foot plantar pressure as objective quantitative measures that could potentially inform clinical decision-making on the return to full weighbearing after an Achilles tendon (AT) injury. Tendon stiffness and foot plantar pressure were measured repeatedly in 15 patients until three months after the AT rupture. Meanwhile, patient reported outcomes assessing the impact on physical activity were evaluated using the Achilles Tendon Total Rupture Score (ATRS). At week two post-injury, stiffness of the injured tendon varied from 6.00 m/s close to the rupture to 8.91 m/s when measured more distally. While near complete recovery was observed in distal and middle regions at week eight, the shear wave velocity in the proximal region recovered to only 65 percent of the contralateral value at week-12. The insole derived assessment of the plantar pressure distribution during walking showed slight sub-optimal function of the affected foot at week-12, while the ATRS score recovered to a level of 59.


The study compared plantar fascia in stretched and relaxed positions in 20 patients with plantar fasciopathy. Patients were assessed bilaterally, with the toes maximally dorsiflexed in the stretched position and feet hanging freely over the end of the table in the relaxed position. The plantar fascia of the most symptomatic foot was significantly thicker when stretched compared with the relaxed position. The plantar fascia was significantly thinner in the frontal plane compared with the sagittal plane in both positions. There was no difference between pressure pain thresholds in stretched or relaxed positions in either foot. These results highlight the importance of how ultrasonography is performed and reported in research to allow for replication.


This retrospective study observed 151 patients with Charcot neuroarthropathy at 30 days, one year and three years post-reconstruction. Overall, 22 (14.6 percent) patients died, and 23 (15.2 percent) patients advanced to limb amputation postoperatively. The risk of mortality was 2.5 times higher in patients with end stage renal disease and 3.4 times higher among patients with peripheral vascular disease. Patients with ankle or subtalar joint reconstruction were 70 percent less likely to return to walking compared to medial column reconstruction.

Practice Management

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As a result of the COVID-19 pandemic many practices have had to limit care delivery or find new ways to keep patients and staff safe. This can include expanding their telehealth capabilities, but it can also mean managing patient flow through interior design and planning. Practices should set clear policies on arrival times, mask compliance and visitors/companions and ensure that patients are notified in advance of their visit. Some practices are eliminating waiting rooms altogether. Consistent and thorough cleaning is critical to infection control, and this applies to furniture and fixtures as well. Practices should also ensure that their employees have dedicated spaces to rest and recharge during long and demanding shifts.


Practice managers should be mindful of the new legal, security and liability issues around the forthcoming COVID-19 vaccinations. For example, law enforcement agencies including Interpol have issued explicit warnings about how organized crime has created multiple revenue streams using COVID-19. In addition to making sure the vaccine is stored correctly, healthcare facilities may need to protect their supplies from theft with a heightened level of physical security. Reports also state that related crimes, such as the sale of counterfeit vaccines and sham cures and medical supplies, will be used for cybercrimes such as phishing and identity theft. This means compliance on the sourcing of any drugs and supplies, their custody, storage and distribution will be more important than ever, as will your IT security procedures and insurance. As vaccines become available healthcare workers and first responders are slated to be among the first in line for vaccination priority. There is also the problem of "alternative science" and its presence among some medical professionals, who object to being vaccinated in general or in some cases. At this point, the legal consensus is that employers can mandate that employees be vaccinated as a condition of continued employment.

Health Policy and Reimbursement

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The US Centers for Medicare and Medicaid Services (CMS) has announced its new voluntary payment value-based Geographic Direct Contracting model. The model will test an approach to improving health outcomes and reducing costs for beneficiaries. Model participants will work within defined geographic regions to maintain and improve care coordination. Specifically, model participants will coordinate care and clinical management for beneficiaries in original Medicare in their region. To help with delivering improved outcomes, participants may create a network of preferred providers. Participants will also work to augment Medicare's current program integrity efforts. Model participants will have the ability to reduce beneficiary cost-sharing for Medicare Part A and Part B services, as well as to offer beneficiaries a Part B premium subsidy. The model will not change how Medicare-enrolled providers care for beneficiaries in original Medicare. Beneficiaries in the model will maintain all of their existing original Medicare benefits and protections.


A study published in JAMA Surgery found that men received 78.7 percent of the 1,235 grants awarded by the US National Institutes of Health (NIH) to surgeons in 2019 and 80.7 percent of the 671 RO1-equivalent grants. Women also received less money than men when they did receive grants for all award types (mean $428,109 vs $499,631), as well as when they received multiple awards (mean $659,343 vs $840,037). There were no Black women, Hispanic women or female orthopedists among the R01-equivalent grant recipients. Although men account for 72.4 percent of Association of American Medical Colleges faculty as of 2019, researchers noted that their share of NIH funding was even greater. Moreover, women and women of color in this study still received fewer research dollars after controlling for professional level.


The US Department of Health and Human Services' (HHS) Office for Civil Rights on Thursday proposed changes to HIPAA Privacy Rule, with the goal of furthering value-based reimbursement and improve care coordination by enabling greater patient and family access to health data. The notice of proposed rule-making, drafted as part of HHS' Regulatory Sprint to Coordinated Care initiative, aims to remove regulations that might impede communication and data exchange between provider organizations and health plans. The agency says the proposed changes would expand individuals' rights to access their own digital health information, boost information-sharing and case management across the care continuum and enable greater family and caregiver involvement during emergencies or health crises. The changes would also offer more flexibilities for disclosures in situations such as opioid overdoses and the COVID-19 public health emergency.


A national survey from Mercer reveals that large U.S. employers saw their smallest healthcare cost increase in more than two decades due to COVID-19, and workers may benefit from that next year. Patients stayed home and out of doctor's offices this year to avoid the global pandemic, and that led to an average 1.9 percent cost hike for companies with 500 or more employees, Mercer found. Those employers were expecting a 3.5 percent increase, said Beth Umland, Mercer's director of health and benefits research. The lowest cost increase since 1997 will help many large employers avoid raising deductibles or doing other things to shift costs to workers in 2021, she added. Many companies also will spend some of what they saved adding programs, like telemedicine, that help improve the health of those covered by their plans.

Medicine, Drugs and Devices

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As of December 4, 2020, the US Food and Drug Administration (FDA) had approved 48 new molecular entities and therapeutic biological products for the year, matching the total for 2019 despite complications from the COVID-19 pandemic. Travel restrictions have hampered inspections and, in some instances, have caused the agency to miss its Prescription Drug User Fee Act (PDUFA) action dates. For pre-approval inspections, FDA noted it has been using "other tools and approaches where possible," such as relying on foreign regulators and requesting detailed records and information from applicants and other inspected entities.


A US Food and Drug Administration (FDA) advisory panel recommended approval of the COVID-19 vaccine developed by Pfizer and BioNTech, clearing the way for the FDA to grant emergency authorization of the vaccine. The approval—by a vote of 17-4 with one abstention after a daylong hearing—came as COVID-19 infections continued surging, claiming about 290,000 American lives. In its vote to approve, the panel said the benefits of the vaccine outweigh the risks for people 16 years of age and older.