News From ACFAS

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ACFAS is here to help you take on your most complicated cases. Join us October 15-16 for Comprehensive Surgical Management of Challenging Cases.

This new interactive course gives you ample hands-on lab time complete with case presentations, lectures, and demos. Spend two days with the experts as you gain new surgical skills while you treat these four complex cases:

• Patient with metatarsus primus varus and short first metatarsal who also has some pain at the 5th MPJ in association with a bunionette deformity
• 18-year-old female presenting with transverse and sagittal plane collapse of the midtarsal joint with maximally pronated subtalar joint
• Middle-aged patient with severe pronation of the midtarsal joint and maximally pronated subtalar joint
• Patient with chronic pain at the anteromedial aspect of the ankle, with CT images revealing absence of the subchondral plate at the site of the lesion with minor cystic changes of the underlying bone

Register now to earn 16 CECH and tackle your most complicated cases. Visit acfas.org now for more information and to secure your spot now. ACFAS is looking for high-quality posters to be presented at the Annual Scientific Conference. Submit your latest discoveries and late-breaking research now to be considered for display at ACFAS 2023, February 9-12 in Los Angeles.

Poster abstracts must be submitted to ACFAS by September 7 to be eligible for review. PDFs of eligible posters are due November 9.

Visit annualconference.acfas.org to view guidelines/criteria and submit your poster today!

Foot and Ankle Surgery

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A study sought to assess a compressed sensing artificial intelligence framework (CSAI) to expedite magnetic resonance imaging acquisition of the ankle. The researchers scanned 30 patients at 3T, yielding perfect correlation between compressed sensing only (CS) and CSAI with an acceleration factor of 4.6-5.3 (CSAI2x). Correlation was excellent for CS and CSAI with an acceleration factor of 6.9-7.7 (CSAI3x), and no significant differences were observed in the depiction of structures between CS and CSAI2x; the same abnormalities were spotted in both protocols. The depiction for CSAI3x was graded lower, although most abnormalities were detected as well. For CSAI2x contrast-to-noise fluid/muscle was higher versus CS, while no differences were identified for other tissues. Signal-to-noise and contrast-to-noise were higher for CSAI3x compared to CS, while the high-resolution axial T2-w sequence enhanced the depiction of tendons and the tibial nerve.


Researchers reviewed data on patients who underwent fluoroscopic and endoscopic calcaneal spur resection (CSR) without plantar fascial release (PFR) for plantar fasciitis with a calcaneal spur. The review involved 47 patients (31 female, 16 male) at a mean age, 56.4 years and a mean body mass index (BMI) of 5.5, with plantar fasciitis with calcaneal spur greater than or equal to 2 millimeters (mm). Mean follow-up duration was 2.7 years, and the mean calcaneal spur length was 5.7 mm. The visual analog scale score improved from 79.6 ± 12.9 mm preoperatively to 5.3 ± 7.3 mm postoperatively. The Japanese Society for Surgery of the Foot score shifted from 54.0 ± 19.1 points preoperatively to 97.5 ± 5.7 points postoperatively. The mean duration to full weightbearing postoperatively was 4.4 ± 4.2 days. Two subjects presented with tenderness, and one presented with hypesthesia at the portal site.


Research was held to assess clinical and radiographic results in 70 patients undergoing distal tibiofibular arthrodesis or stabilization between 2003 and 2019. Surgical factors, revision surgeries and American Orthopaedic Foot & Ankle Society (AOFAS) ankle-hindfoot scores were amassed. Radiographs were independently evaluated by four surgeons. Mean AOFAS scores improved from 48 ± 16 preoperatively to 85 ± 14 at a median follow-up of 31.1 months. Mean Kellgren scores rose from 2.1 ± 1 to 2.5 ± 1, and the mean medial clear space decreased from 3.2 millimeters (mm) ± 0.8 mm to 2.8 mm ± 0.8 mm, with no disparities between the arthrodesis and stabilization cohorts. No patients developed arthroplasty or fusion. Patients exhibited significant functional improvement following distal tibiofibular arthrodesis and stabilization, while progression of arthritis was clinically insignificant.

Practice Management

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Medical practices have a responsibility to shield patient records from hackers. A security risk assessment should be conducted, and investments should be made in staff training. Also recommended are software patch updates, multifactor authentication for all devices, a password policy and encryption. Correct firewall configuration is a necessity, while guest Wi-Fi and medical practice networks should be separated and role-based access to electronic health records must be guaranteed. Systems should also be backed up, while cyber liability insurance should be considered. Finally, the practice should retain a cyber liability attorney and consider managed cybersecurity services.


Addressing a medical-worker shortage and accommodating an inundation of aging baby boomers will require healthcare companies to revamp current hiring models. The at-need model of healthcare recruitment is perhaps the biggest hindrance, and passive job candidates, while not necessarily superior to active candidates, comprise 75 percent of the available market. A talent management system or recruitment software can provide a reliable and efficient means of finding, organizing and enlisting employees. Recruitment software can simplify the hiring process and consolidate an organization's pipeline and team into a single collaborative and virtual space where candidates and current workers can partner on high-priority opportunities. Any staffer with clearance to use the talent management software can also access, record and edit all notes on individual candidates.


New research compared the racial and ethnic composition of applicants and matched residents from 11 competitive medical and surgical specialties between 2013 and 2018. The cumulative number of applicants ranged from 1,142 in radiation oncology to 17,917 in emergency medicine. The ratio of White applicants ranged from 0.52 in radiology and radiation oncology to 0.67 in orthopaedic surgery, while the proportion of White matched residents ranged from 0.54 in radiation oncology to 0.70 in orthoapedic surgery. The difference in proportions between White applicants and matched residents ranged from 0.02 in radiation oncology to 0.07 in obstetrics and gynecology. The proportion of White matched residents was much higher than that of applicants in 54.5 percent of the specialties.

The proportion of underrepresented applicants ranged from 0.08 in otolaryngology to 0.19 in obstetrics and gynecology. The proportion of underrepresented matched residents spanned from 0.06 in dermatology, orthopaedic surgery, otolaryngology, plastic surgery, radiation oncology and urology to 0.11 in obstetrics and gynecology. The proportionate distinctions between underrepresented applicants and matched residents ranged from -0.08 in obstetrics and gynecology to -0.02 in otolaryngology. The proportion of matched underrepresented residents was substantially lower than applicants across all specialties. Systemic disparities within the residency selection process are implied by the overrepresentation of White matched residents and underrepresentation of non-Asian racial and ethnic minority groups across all specialties.

Health Policy and Reimbursement

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The US Supreme Court's strikedown of Roe v. Wade has created a dilemma for physicians caught between their inability to fulfill their professional obligations to pregnant patients and their oath to do no harm. An amicus brief in the case of Dobbs v. Jackson states: "The ban forces clinicians to make an impossible choice between upholding their ethical obligations and following the law." Stephanie Mischell, a family physician in Dallas and fellow with Physicians for Reproductive Health, says pregnant patients in Texas must negotiate a morass of restrictions and bans on abortion care. Louise King at Brigham and Women's Hospital warns that the high court's ruling will exacerbate the situation. "Laws will exist that ask [physicians] to deprioritize the person in front of them and to act in a way that is medically harmful," she explains. "And the penalty for not doing so will be loss of license, money loss, potentially even criminal sanctions. How can you possibly resolve that conflict?"

Doctors in states with abortion restrictions that have just come into force, or soon will, are scrambling to understand the specifics of restrictions in cases where complications arise. Without clear language, King says both physician and patient can only "watch somebody get sicker and sicker and sicker until some point — and where is that point? — where it's OK to intervene and we won't be exposed to criminal liability."


Government watchdogs on June 28 told the US House Energy and Commerce subcommittee on oversight and investigations that a crackdown on Medicare Advantage plans is necessary, citing audits and reports indicating that plans have denied patients access to healthcare while overcharging the government billions of dollars. They also called for limits on home-based "health assessments." According to Erin Bliss, a US Department of Health and Human Services assistant inspector general, $2.6 billion was paid by Medicare in 2017 for diagnoses only backed up by such assessments, but for 3.5 million members, there were no records that they received care for conditions diagnoses via the assessments. Further, the watchdogs said the US Centers for Medicare and Medicaid Services should revive an audit program that had been expected to recover over $600 million in overpayments but is over a decade behind in completing audits.


In a letter to US Department of Health and Human Services Secretary Xavier Becerra, a group of 100 lawmakers called on the Biden administration to implement Section 1498 of federal law or use march-in rights under the Bayh-Dole Act to bypass pharmaceutical patents in an effort to reduce prescription drug prices. The lawmakers wrote, "Exercising these authorities would be extraordinarily popular — about 80 percent of voters favor breaking patent monopolies to reduce drug prices." The US National Institutes of Health has been petitioned in the past to use march-in rights but has regularly denied such efforts. However, the agency is currently assessing a petition filed last November regarding enzalutamide, a prostate cancer drug.

Medicine, Drugs and Devices

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A new opinion by a US Court of Appeals for the Federal Circuit panel ruled that Novartis Pharmaceuticals' patent on the dosage regimen for the multiple sclerosis drug Gilenya lacked an adequate description as required by the Patent Act. This requires inventors to precisely define what is claimed to demonstrate that they possess the invention, which Armond Wilson founding partner Michelle Armond said gives generic drugmakers a new defense tactic to challenge the validity of name-brand drugs. "Written description can often be a significant issue in pharmaceutical cases," she noted. "You can expect that other generic drugmakers are going to pay attention to this and try similar approaches and strategies on patents in that space that have negative limitations."


The US Supreme Court sided with two doctors who were convicted of prescribing hazardous opioids without valid medical justification in breach of federal law. Their attorneys argued in their appeal that a jury should have been able to consider whether they reasonably believed that they were acting within professional boundaries, which the government contended was unnecessary. Justice Stephen Breyer wrote that for the prosecution to succeed, the government "must prove beyond a reasonable doubt that the defendant knowingly or intentionally acted in an unauthorized manner." Some courts have said a doctor's good faith conviction that he or she was acting within medical norms is irrelevant to criminal liability, while others say the government must demonstrate that a physician knowingly prescribed drugs illegally, and that the law was not intended to criminalize well-intentioned conduct when a doctor prescribes drugs to treat patients with legitimate medical requirements.

The high court's ruling will make it easier for patients to receive certain treatments. University of Texas School of Law professor Steve Vladeck explained that the outcome "puts the burden on the government when prosecuting doctors for wrongfully prescribing controlled substances, to show not only that the prescription did not serve a legitimate medical purpose, but that the doctor knew as much when they wrote it. In that respect, it likely arms doctors going forward with a strong defense that they made a good-faith mistake, which could help them avoid criminal liability, although perhaps not civil or ethical repercussions."


A University of Michigan analysis of Medicare data through 2021 found the traditional Medicare population used telehealth during the pandemic to access care, but have not been using the platform excessively. About one-third of traditional Medicare beneficiaries had at least one telehealth visit last year. The researchers determined that about 9 percent of all outpatient appointments made by people with traditional Medicare coverage were virtual in the latter half of the year, marking a decline in virtual visits compared to the period between mid-2020 and mid-2021, but a big gain compared to before the pandemic in 2019. The implication is that the Medicare population, comprised mainly of older Americans, is using the platform as a replacement for in-person care, rather than just because they can.