News From ACFAS

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The ACFAS Nominating Committee is looking for the best and brightest to participate in the upcoming election to serve on the College’s Board of Directors. If you are an ACFAS Fellow, believe you are qualified and would like to help lead the profession, submit your nomination application by September 23, 2023. Visit acfas.org/nominations for more information, including complete details on the recommended criteria for election candidates.

The Nominating Committee will announce recommended candidates to the membership on October 26, 2022. Online voting for members will start no later than November 28, 2022 and will end on December 14, 2022. The elected directors will be announced shortly thereafter and will start their term of service at the ACFAS 2023 Scientific Conference on February 9-12, 2023 in Los Angeles. Join expert faculty November 10-11 in Chicago for a deep dive into podiatric internal fixation surgery. Comprehensive Fixation for the Ankle and Foot: A Resident's Course offers a small resident to faculty ratio allowing for close mentorship, and a redesigned agenda focused on shorter lectures with ample time for hands-on learning. This course offers real-life experience in:

• Major rearfoot and ankle arthrodesis techniques
• Complications that can result from internal and external fixation
• Specialty plating and external fixation techniques
• Preoperative planning
• Psycho-motor skills

Earn 17.25 CME credits as you learn about and execute the principles and techniques for stable internal fixation for fracture management, aspects of diagnosis, and treatment and subsequent management of these injuries.

Visit acfas.org/skills for more information and to register today!

Foot and Ankle Surgery

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Researchers conducted a study to compare the functional and radiographic outcomes of two minimally invasive techniques in the treatment of Sanders type II and III displaced intra-articular calcaneal fractures (DIACFs) by using K-wires or cannulated screws without bone grafts. A prospective, randomized controlled study was conducted on 28 patients (34 feet) with Sanders type II or III DIACFs, treated by closed reduction and fixation using cannulated screws or K-wires, at the Orthopaedics Department of Sohag University Hospital between April 2020 and February 2022. Functional assessment was done by American Orthopaedic Foot and Ankle Society (AOFAS) score and VAS for pain.

Radiographic assessment was done by measurement of three calcaneal angles (Gissane, Böhler's, and posterior facet inclination angles) and three calcaneal distances (height, length, and width of the calcaneus). Mean ages of patients at the time of operation were 34.8 years for the cannulated screw group and 36.6 years for the K-wire group. A vast majority of patients were males (78.6 percent). Involvement of the right side in the cannulated screw group was 57.1 percent and that in the K-wire group was 47.9 percent. Mean operative time was significantly shorter among the K-wire group (42 min) compared to the cannulated screw group (57 min). Mean AOFAS score was higher among the cannulated screw group (85.9 points) compared to the K-wire group (75.8 points). Final VAS was significantly better among the cannulated screw group compared to the K-wire group. Mean time of radiographic union in the cannulated screw group was 8.9 weeks and that in the K-wire group was 10.1 weeks. Patients in the cannulated screw group had better functional and radiographic outcomes and a lower rate of subtalar arthritis than patients in the K-wire group. K-wires had advantages of reduced operative time, and easy removal as an outpatient procedure.


Peripheral nerve blocks are regional techniques in orthopedic surgeries to control postoperative pain and enable early discharge from hospital. However, anesthesia protocols for foot and ankle surgeries of institutes do not include multimodal analgesics, including peripheral nerve blocks. The objective of the study was to compare spinal anesthesia with peripheral nerve block against general anesthesia with peripheral nerve block for elective foot and ankle surgeries.

Patients were treated for elective foot and ankle surgery under general anesthesia (using propofol, 0.05 mg/kg dezocine, and 1 percent sevoflurane; GA cohort, n=112) or spinal anesthesia (using 0.5 percent bupivacaine, propofol, and 0.05 mg/kg dezocine; SA cohort, n=132) or patients were treated for elective for foot and ankle surgery under general anesthesia (GL cohort, n=115) or spinal anesthesia (SL cohort, n=160) with the use of peripheral nerve block (the sciatic nerve blocks and adductor canal nerve blocks using 0.25 percent bupivacaine and 0.1 mg/kg dexamethasone). Propofol was administered in fewer amounts if anesthesia was used with the peripheral nerve block. Patients of the GL cohort were transferred to ward 36 minutes (mean) earlier than those of the SL cohort. None of the patients of the GL and the SL cohorts received intraoperative opioid(s) for the management of pain.

Patients of the GL and the SL cohorts reported postoperative falls within 1 day after surgeries during movement. Patients of the SL cohort experienced more frequently difficulty with sleeping. Patients of the GL and the GA cohorts reported nausea and vomiting. Only patients of the GL cohort were required usage of vasoactive drugs. The study provides information to anesthesiologists and surgeons regarding anesthesia techniques for elective foot and ankle surgeries for better surgical outcomes.


The present study assesses the results of a minimally invasive surgical technique for acute and chronic ankle instability management. The present case series study retrospectively evaluated 40 patients undergoing arthroscopic-assisted percutaneous ankle ligament reconstruction from 2013 to 2019. The present study included 17 males and 23 females with an average age of 38.3 years old. Postintervention follow-up using American Orthopaedic Foot and Ankle Society (AOFAS) Ankle-Hindfoot scores identified improvement of > 30 points in function and pain control. The most frequently occurring associated injuries were osteochondral (35 percent). No patient required reintervention or had infection during follow-up. The technique in the present study is easy and achieves satisfactory results for function and pain control, the researchers concluded.

Practice Management

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Private medical practices operate in a competitive market, so it is essential to keep patients satisfied by keeping the medical office clean. The US Centers for Disease Control and Prevention and the US Occupational Safety and Health Administration have established research-based industry standards for medical office cleaning designed to reduce cross-contamination and the risk of healthcare-associated infections. For surfaces in high traffic areas such as the waiting room, staff should wipe furniture and surfaces down with disinfectants registered with the US Environmental Protection Agency. Common high-traffic surfaces include drawer handles, faucets, cabinets, chairs, and sinks. In the reception area, these surfaces include phones, computer equipment, clipboards, door handles, and counters.

In addition, dusting at least three times a week will help patients with dust allergies; these procedures should be performed even when working with a professional cleaning service. It is also essential to conduct bathroom checks regularly at all medical clinics. Staff should follow a schedule for cleaning countertops, disinfecting toilets, sinks, and other fixtures. The bathroom also should be stocked with soap, paper towels, and toilet paper. The reception area should be clutter-free and organized. Staff should remove unnecessary paperwork, pens, and clipboards from the reception desk. Any files that are not being used should be returned to their proper place. The surfaces patients use to fill out forms or other materials should be wiped clean. These steps will give an impression that the practice takes patients' health needs seriously.


Many economists are predicting that the U.S. economy will experience a downturn. Businesses that continue to market during economic difficulties recover more quickly in the long run. Practices can encourage patient retention by using such tools as email marketing to encourage patients to schedule follow-up visits and implementing practice growth technologies that leverage a practice's online presence. Prospective patients become aware of what makes a facility unique from similar practices and can book appointments online through practice management software. Practices that send paper statements by mail should transition to billing software. Most patients prefer to pay their medical bills electronically, yet 90 percent of providers have not implemented billing software.

The use of patient payment collection technology may enable an office to reduce its outstanding invoice balance by as much as 30 percent. An omnichannel payment collection solution can itemize the charges of a medical bill to enable patients to see their remaining balance after insurance coverage. In addition, practices can identify areas to improve by evaluating such things as how the practice's website drives business and whether the online reputation is positive and influential. Practices also should examine if the workflow in the front office is streamlined and whether performance metrics are being tracked. The practice needs to identify weaknesses by comparing it to similar facilities of the same specialty. Finally, both employees should be asked to share insights on the roles they fill, workflows, operational strengths, and weaknesses, while patients should be asked their opinions.


A study published in JMIR Medical Informatics indicates that greater telehealth use may lead to more after-hours work for providers, potentially worsening burnout. Included were 2,129 physicians across various subspecialties, mainly concerning internal medicine, ambulatory surgery and general medicine. The frequency of telehealth use increased sharply at the start of the COVID-19 pandemic, but in-person patient volume declined. The level of work outside of work (WOW) grew when accompanied by telehealth at all stages of the pandemic, while any decrease in WOW stemmed from a lower clinical load rather than telehealth assistance. The researchers concluded that telehealth cannot reduce WOW.

Health Policy and Reimbursement

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US President Joe Biden on Aug. 16 signed into law the Inflation Reduction Act — a legislative package that sets its sights on, among other targets, reducing prescription drug prices and the overall cost of health care. Under the new law, the cost of insulin for Medicare beneficiaries will be limited at $35 a month, starting next year, and older adults will qualify to receive certain vaccines at no cost. In addition, the measure extends for three more years Affordable Care Act subsidies provided under the 2021 American Rescue Plan. Benefits not slated to kick in until later include a $2,000 ceiling on out-of-pocket drug costs for Medicare enrollees beginning in 2025 and Medicare authorization to negotiate prices on certain drugs, starting the following year.


As of Jan. 1, The Joint Commission set new accreditation standards for hospitals, primary care clinics, behavioral health centers, and critical access facilities. The objective is to accelerate equity efforts within healthcare organizations. The updated standards, among other things, call for designating an officer to lead a strategy for reducing health disparities and screening patients for social determinants of health.

The commission also requires accredited organizations to add demographic breakdowns for quality and safety data to help entities pinpoint disparities in health outcomes and develop an action plan to remove them. Once a plan is made, providers will need to monitor their progress and consistently update internal leaders and staff. Ana McKee, executive vice president and chief medical officer of The Joint Commission, says the commission's new effort is "about healthcare leaders. They have not been held accountable for what turns out to be very costly disengagement with these communities. The costs are huge to society, but also to the organizations that participate in risk contracting and bundle payments."

McKee adds that The Joint Commission will offer educational programs and other resources to help health systems adhere to the new standards. Meanwhile, the National Committee for Quality Assurance, The National Minority Quality Forum, and the US Centers for Medicare & Medicaid Services have started to merge equity metrics into accountability programs for health insurers.


In the year since Donald Berwick and Rick Gilfillan took aim at Medicare Advantage (MA), health policy experts are offering a counter-perspective. Berwick and Gilfillan basically argued that any financial incentive was fundamentally wrong and destructive to the ideals of the Medicare program and of true value-based contracting. An opinion piece by a number of policy leaders in Health Affairs contends that their argument diverges from the factors underlying higher MA payments in MA versus traditional Medicare (TM). "We agree that there is evidence for higher payment to MA plans relative to TM," they write. "What is unclear is whether this is due to an overcoding problem in MA or an undercoding problem in TM. The incentive in MA is for physicians to code comprehensively for diagnosis (using International Classification of Diseases [ICD] codes, specifically ICD-10 codes); the incentive in TM is for physicians to code procedures (using Current Procedural Terminology [CPT] codes)."

The authors continue: "The important purpose of disease-based risk-adjustment is to appropriately pay MA plans for members' 'burden of disease.' Instead of abandoning disease-based risk adjustment, policymakers should deal with the underlying incentives related to coding. The correct short-term solution is to adjust for relatively higher coding intensity in MA. In the medium term, instead of abandoning disease-based risk-adjustment in MA, CMS should introduce disease-based risk adjustment in TM." Afterward, the authors note that "it would be appropriate to look at improving risk adjustment in both programs to account for patient differences, for example in both functional status and social determinants of health (SDOH)."


A new report from the American Hospital Association (AHA) found hospital patients are sicker and more medically complex than they were prior to the COVID-19 pandemic, causing hospital costs for labor, drugs and supplies to surge. "Combined with rapidly rising economy-wide inflation and reimbursement shortfalls, these mounting costs are threatening the financial stability of hospitals around the country," the report says. Hospital patient acuity as quantified by average length of stay rose nearly 10 percent between 2019 and 2021, including a 6 percent gain for non-COVID-19 Medicare patients as the pandemic played into delayed and avoided care. This year, patient acuity as reflected in the case mix index climbed 11.1 percent for mastectomy patients, 15 percent for appendectomy patients and 7 percent for hysterectomy patients. With hospitals and health systems already under significant financial pressure, AHA is asking Congress to halt its Medicare payment reductions to hospitals and other providers; extend or make permanent waivers that enhance efficiency and access to care; extend expiring health insurance subsidies for millions of patients and hold commercial insurers to account for improper and onerous business practices.

Medicine, Drugs and Devices

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Alphabet, Amazon, Apple and Microsoft are ramping up their moves into the healthcare market through new investments and partnerships. Amazon Web Services has forged alliances with Geisinger, University of California Davis Health, Tufts Medicine and Oracle Cerner. Four years ago, Amazon entered into a definitive merger agreement to purchase online pharmacy PillPack for about $1 billion. More recently it announced plans to purchase virtual and in-person primary care company One Medical for $3.9 billion to offer more convenient and less costly healthcare in-person and virtually. Meanwhile, Apple aims to convert its consumer products into portable patient health hubs and clinical research tools; this includes enhancing items like the Apple Watch and iPhone with new health features.

Alphabet is pursuing strategic hospital partnerships with health systems like New York-based Northwell Health by leveraging its cloud platform and artificial intelligence (AI) capabilities. Northwell will use Google's cloud, AI and machine learning augmentations to generate predictive clinical insights, digital scheduling, automated payer interactions and intelligent visit summaries. Finally, Microsoft is competing with Alphabet and Amazon Web Services in the healthcare cloud sector through various deals and acquisitions. One partnership with University of Pittsburgh Medical Center will help the health system sift through over 13 petabytes of structured clinical data and 18 petabytes of imaging data to produce insights that improve patient care.


The data of hundreds of thousands of consumers may have been compromised in a ransomware attack in April at New York-based revenue-cycle management company Practice Resources. The company reported engaging third-party experts to secure its systems and probe the incident, and in June determined the patient data of its provider clients may have been breached. The data covered 942,138 patients, according to a report Practice Resources submitted to the US Health and Human Services (HHS) Department's Office for Civil Rights. “Since the incident, we have implemented a series of cybersecurity enhancements and will soon roll out others,” the company stated in a notice. This attack represents the sixth-largest data breach reported to HHS this year, following incidents disclosed by Shields Health Care Group, Professional Finance Company and others. A report from risk consulting firm Kroll also estimated that one-third of cyber threats targeting healthcare in the last quarter were ransomware attacks.