News From ACFAS

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The ACFAS Clinical & Scientific Research Grant Program is open! Thanks to support from PICA and the ACFAS Regions, the College will again be offering funding of up to $75,000 for an established investigator and $25,000 for a new researcher.

Letters of intent should be submitted by September 15 at 5pm CT and final applications are due by October 15 at 5pm CT. Awards will be announced in December and funding will be provided in January 2023. All applications must follow a modified NIH R21 format.

Visit acfas.org/ResearchGrant for more information. ACFAS is still 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 case series was conducted on 10 patients who underwent revision neuroma excision through a dorsal approach following a failed primary interdigital neuroma excision to determine complications and outcomes using validated patient-reported outcome measures (PROMs). The patients had preoperative and minimum one-year postoperative Patient-Reported Outcomes Measurement Information System (PROMIS) scores. The researchers saw significant improvements in the PROMIS pain interference, pain intensity and global physical health, while one patient experienced recurrence of their neuroma four years after surgery. Further research with comparative study designs is warranted to ascertain if one procedure is superior to the other.


Researchers compared 31 patients undergoing minor lower extremity amputation with indocyanine green (ICG) dye with 62 controls subjected to traditional methods. Minimum follow-up of nine months was realized, leaving 93 patients for analysis. Healed amputation within 60 days of follow-up indicated success. There was uneventful amputation healing in 35.5 percent and 33.9 percent of ICG and control patients, respectively. No significant difference in outcomes was observed between groups or success versus failure. Patients undergoing minor lower extremity amputation with the use of ICG fluorescence angiography had no statistically inferior outcomes to patients who underwent the same procedures with traditional perfusion evaluations. Further research involving the use of this technique is called for.


A study was held to assess the prevalence of and predisposing factors for osteolysis and its effects on clinical outcomes after total ankle arthroplasty (TAA). A total 236 patients (250 ankles) that underwent primary TAA using a mobile-bearing HINTEGRA prosthesis, with a mean follow-up of 83.5 months, were divided into an osteolysis cohort (79 ankles) and a non-osteolysis cohort (171 ankles). The mean time of detection was 28.8 months postoperatively in the osteolysis group. Forty ankles were tracked without surgery, another 29 ankles received bone grafting and exchange of the polyethylene inlay and the remaining 10 underwent revision TAA or arthrodesis. Patients with osteolysis had significantly lower clinical outcome variables at the final follow-up than those lacking osteolysis. Rheumatoid arthritis was the only identified predisposing factor significantly associated with a higher prevalence of osteolysis.

Practice Management

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According to a recent report from Kroll, the number of healthcare entities targeted by cybercriminal groups rose 90 percent in the second quarter of 2022. These groups continue to take advantage of phishing and vulnerabilities to launch ransomware attacks, but they also have started exploiting external remote services, the report says. There was a 700 percent rise in the use of remote desktop protocols and virtual private networks, among other external remote services, by cybercriminals looking to access healthcare systems. Kroll found that healthcare professional services are now the top targeted sector, representing more than 20 percent of its cases in the second quarter, up from 11 percent in the first quarter.


US consumers are likely to be hit with higher medical expenses soon as efforts to align payment rates with labor costs are implemented. Although Medicare's projection for the current fiscal year assumed hospital costs would increase by about 2.7 percent, in reality those costs are expected to top 5 percent. The latest monthly update to the Consumer Price Index indicates overall inflation near 40-year peaks, with prices rising by 8.5 percent over the past 12 months, fueled by double-digit growth for items like gas, food and vehicles. Consumer prices for medical care services have expanded 5.1 percent, mostly thanks to higher profits for private insurers. Prices for medical care commodities have seen just 3.7 percent growth over the past 12 months, but rising costs are adding pressure to healthcare providers' balance sheets.

"We're dealing with really significant rates of increases in input prices directly related to inflation, and a lot of that is driven by the labor side," said American Hospital Association (AHA) CEO Richard Pollack. "Hospitals are experiencing pretty significant reductions in their operating margins, if you look at the numbers we're struggling." A newly updated payment rule from the Centers for Medicare and Medicaid Services assumes a 4.1 percentage point hike in input costs next year, which the AHA criticized for falling short of its own estimates for the growing cost of hospital care. Given that Medicare's rates are only based on forward-looking forecasts, a mechanism for "catch-up" price growth is lacking.


Patient volume and fee structure are key factors to be weighed prior to opening a direct care practice. Research indicates most primary care physicians in traditional practice carry a patient panel of 1,200-1,900 patients, while direct care physicians rarely enroll more than 1,000 patients, with most capping volume at 200-600 patients. Considering how many patients can be accommodated based on the physician's desired work schedule and support staff is a good stating point for calculating panel size. Physicians must cautiously mull how they want to promote access to their practice, especially in the earliest stages of compiling a patient panel. They should avoid offering 24/7/365 patient access to patients and instead draft practice policies to guarantee reasonable access while marking boundaries to ensure physician work-life balance.

Physicians will manage workload by freezing new patients or holding a waiting list to limit the number of new patients daily. They can also avoid doing "everything" on the first visit with a new patient and instead set up more frequent but shorter sessions until all of the patient's needs have been addressed. Determining a price structure is the next step, and direct primary care practices charge a monthly membership fee, often based on patient age. Direct specialist practices may charge a monthly or a per-visit fee, while chronic disease specialists often have patients pre-pay for a certain number of visits per year based on an appropriate disease management schedule to ensure they do not miss out on necessary care.

Health Policy and Reimbursement

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Nearly 49 million people, most of them older Americans, get prescription drug coverage through Medicare, yet many find that it does not go very far. Low-income people qualify for government subsidies, so those in the middle class are hit hardest by high drug costs. The Inflation Reduction Act could save many Medicare beneficiaries hundreds, if not thousands of dollars a year. Its best-known provision would empower Medicare to negotiate prices with drug makers with the goal of driving down costs. The legislation would also take more direct steps to keep money in people’s pocketbooks, though they would be phased in over time. Beginning next year, insulin co-payments for Medicare recipients would be capped at $35 a month. As of 2024, those with costs high enough to qualify for the program’s "catastrophic coverage" benefit would no longer have to pick up 5 percent of the cost of every prescription. Starting in 2025, out-of-pocket costs for prescription medicines would be capped at $2,000 annually. Between 2009 and 2018, the average price more than doubled for brand-name prescription drugs in Medicare Part D, the Congressional Budget Office found. Between 2019 and 2020, price increases outpaced inflation for one-half of all drugs covered by Medicare, according to an analysis from the Kaiser Family Foundation.


A 2008 experiment conducted in Oregon before passage of the Affordable Care Act estimated that more eligible children are enrolled in Medicaid once adults in their household also sign up. After three months, for every nine adult enrollees, one additional eligible child was also enrolled. While more children were covered in the short term because of the experiment, many remained uninsured, and enrollment gradually diminished. Researchers say enrolling children into Medicaid costs about four times less than it does for adults. Although more research is necessary to find out why more parents do not enroll their eligible children for Medicaid, factors like lack of knowledge on eligibility and perceived social stigma are clear contributors.


A new report from the Medicaid and CHIP Payment and Access Commission found that only 3 percent of Americans transitioned to Affordable Care Act exchange plans within a year of leaving Medicaid or the Children's Health Insurance Program (CHIP). The report found that 3.9 percent of adults in enrolled in Medicaid and 3.3 percent of children enrolled in separate CHIP transitioned to exchange coverage, versus only 1.6 percent of children enrolled in Medicaid in states with separate CHIP. The study also found that most beneficiaries disenrolled from Medicaid or CHIP in 2018 either returned to those programs within a year or opted not to enroll in another insurance affordability program, potentially due to premiums or administrative barriers to enrollment, among other issues.

Medicine, Drugs and Devices

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The US Centers for Medicare and Medicaid Services (CMS) seeks to improve the much-maligned Medicare Advantage (MA) program via a request for information on how MA plans can improve the program's equitability, accessibility, innovation, affordability and collaboration-friendliness. CMS is soliciting plans for better data about race, ethnicity and language; sexual and gender identity; people with disabilities and language/communication difficulties; cultural identity and religious preferences; socioeconomic need and people in rural and underserved communities. The agency is also seeking input on MA plan challenges in "obtaining, leveraging or sharing" socioeconomic data, with insights on supplemental benefit use and outcomes, utilization management applications, value-based contracting and competition dynamics sought as well. Questions on data exchange and interoperability cover key technical decisions faced by MA plans and providers, and opportunities for the Trusted Exchange Framework and Common Agreement to support improved health information exchange for use cases pertaining to plans and providers. Finally, CMS wants detailed information on MA plan algorithms, including prediction targets and testing and bias on differential outcomes and mitigation.


The US Food and Drug Administration (FDA) reported contamination in two diabetes drug, some batches of which contain an unusually high level of the impurity Nitroso-STG-19 (NTTP) — a potential human carcinogen. In the interest of preventing a shortage, the regulator indicated it would allow distribution of sitagliptin (Januvia—Merck) and sitagliptin plus metformin HCl (Janumet—Merck) to continue for now. The manufacturer, which said it adopted additional quality controls to ensure the products fall within interim acceptable impurity levels, also assured that the supply of the drugs would not be affected. The interim acceptable intake amount of up to 246.7 nanograms per day, according to FDA scientists, minimally increases cancer risk compared with lifetime NTTP exposure at a level of 37 nanograms daily.


A research team led by the University of Illinois at Urbana-Champaign has developed a drug compound able to combat more than 300 types of drug-resistant bacteria in the laboratory and may eventually be used to treat infections in humans, according to a study published in ACS Central Science. The compound, fabimycin, targets gram-negative bacteria. The researchers made a series of structural modifications to an antibiotic active against gram-positive bacteria to enable it to act against gram-negative strains. The study authors wrote that fabimycin "proved potent against more than 300 drug-resistant clinical isolates, while remaining relatively inactive toward certain gram-positive pathogens and some typically harmless bacteria that live in or on the human body." The researchers also noted that "FabI inhibitors," from which the fabimycin compound was derived, have advanced to clinical trials for Staphylococcus aureus infections, but not for infections caused by gram-negative bacteria, which the researchers described as having a "formidable outer membrane" and "pumps." They also found that fabimycin was able to reduce the amount of drug-resistant bacteria in mice with pneumonia or urinary tract infections to pre-infection levels or below. The study found "impressive activity" against clinical isolates of Escherichia coli, Klebsiella pneumoniae and Acinetobacter baumannii.