News From ACFAS

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Kick off ACFAS 2023 a day early on February 8 with a new lineup of Pre-Conference Workshops! This year’s workshops are sure to have something for everyone and cover a wide range of innovative trends and topics in foot and ankle surgery.

• MIS: From Reconstruction to Trauma (Cadaveric)
  Osseous MIS procedures are undoubtedly becoming more prevalent and require a unique skill set in terms of osteotomy techniques and fixation which this workshop will cover.
• Coding and Billing for the Foot and Ankle Surgeon
  Get properly reimbursed for the care you provide! Hear what’s new in coding for 2023 as you participate in surgical coding scenarios.
• Surgical Management of Challenging Cases (Cadaveric)
  This hands-on workshop revolves around two distinct challenging cases and how to handle them.
• Soft Tissue (Cadaveric)
  This workshop covers soft tissue reconstruction of the foot and ankle, including Achilles repair, FHL transfer, Deltoid repair, and more!
• Residents Day
  Pick up tips from the experts as you complete your post graduate education.
• Residency Directors Forum
  Geared to assist resident educators in optimizing their resident review and oversight.
• Coding Fundamentals
  Start or refresh your coding and billing foundation. This course is ideal for anyone who wants to learn more basic coding and billing terminology.

ACFAS 2023 will be held February 9-12 in the L.A. LIVE entertainment campus. Visit acfas.org/asc to learn more and register for both pre-conference programs and ACFAS 2023. Get expert advice and real-world tips when you join us this October 12, 19 and 26 for the new ACFAS Practice Management Webinar Wednesday.

This three-part series offers a chance to hear what insurance companies are looking for when submitting for reimbursement, how to know if your practice is hitting those important success indicators and how to prepare yourself for a malpractice case.

Insurance Reviews: Get the Inside Scoop for Proper Reimbursement
October 12 | 7-8:30pm CT | 1.5 CME
Maryellen Brucato, DPM, FACFAS; David Wander, DPM, FACFAS and Kyle Berger, CPB
Don’t miss the behind the scenes look at the dos and don’ts of surgical billing from both the insurance reviewer and the biller’s sides. Learn some documenting pearls to help your surgeries get paid and what to do in an insurance audit.

How Do I Know If My Practice is Doing Well?
October 19 | 7-8:30pm CT | 1.5 CME
Bela Pandit, DPM, FACFAS and Heraj Patel, DPM, FACFAS
Listen in as faculty show you how to do a deep dive analysis of your practice by accurately determining and measuring your top revenue makers…and losers…and how to adjust accordingly—all without hiring an outside consulting company!

Malpractice Preparation: Because it Happens to Everyone
October 26 | 7-8:30pm CT | 1.5 CME
Ellianne Nasser, DPM, FACFAS; Ross Taubman, DPM; Al Ng, DPM, FACFAS; Barry Rosenblum, DPM, FACFAS and Maryellen Brucato, DPM, FACFAS
While nobody can fully exempt themselves from a possible malpractice case, experts share some tools to help you avoid getting into litigation with patients. You’ll also hear tips and pearls for documentation, peri-operative management and discussions on complications with patients.

Register for webinars individually or save when you register for all three! Visit acfas.org/practicemanagementeducation for more information. Join us Saturday, November 19 for the ACFAS First Ray Virtual Symposium - where engaging sessions allow you to drive the discussion!

During this live, interactive event you’ll hear expert faculty discuss surgical options to correct first ray deformity, along with complication and revision options. After the symposium ends, extend your learning experience as you interact with peers and faculty through the online discussion forum.

Can’t make the live symposium? Register to access the on-demand recordings and still earn 4 CME. Visit acfas.org/firstrayvirtualsymposium to register for live, virtual education you can use! Your 2023 ACFAS membership is just a click away!

Renew your membership today to keep getting valuable member benefits, including robust education and professional development offerings, practice growth and management tools and our top-rated Annual Scientific Conference.

This year, we're making it easier than ever to maintain your member benefits with our new auto renewal option. Enroll when you renew online and ensure you don't forget to renew in the future.

Please reach out to the Membership Department at membership@acfas.org or visit the Member Center at acfas.org if you have any questions about your member benefits. A new issue of FootNotes is here to give your patients seasonal tips to keep their feet and ankles healthy through another fall season!

In this issue, you’ll find ways to keep young athletes’ feet and ankles safe through the new fall sports seasons, tips for making the switch from sandals to shoes safely, and how to keep feet and ankles protected during fall yardwork.

Use this issue of FootNotes however you want to help maximize your reach with patient education and marketing your practice. The cus­tomizable second page is ready for you to add your practice information so you can keep copies in your office, post it to your practice website and share it on your social media ac­counts.

Access more free tools to help up your practice marketing game by visiting acfas.org/marketing.

Foot and Ankle Surgery

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A study sought to assess the effectiveness of platelet-rich plasma (PRP) in 62 patients with acute Achilles tendon rupture treated via endoscopy-assisted percutaneous repair. At 2-year follow-up, The Achilles Tendon Total Rupture Score did not significantly differ between the PRP and non-PRP groups, although it did improve with time in both cohorts. The rate of return to sports and time to return to play also did not differ. Calf circumference ratio and ankle range of motion (ROM) were assessed at six months, 12 months, 18 months and 24 months. The PRP group had better ankle ROM and a higher calf circumference ratio at six months, although no between-group differences in calf circumference ratio, ankle dorsiflexion and plantarflexion were noted at 24 months. This indicates that PRP augmentation did not improve functional and clinical outcomes.


A retrospective single-center study evaluated the impact of the Ilizarov technique on congenital pseudarthrosis of the tibia. Intramedullary rods were used in nine cases and iliac bone graft was used in 12 cases, while an orthosis was applied until follow-up was concluded in all 16 patients. The patient cohort included 11 males and five females, with an average age of 5.4 ± 2.8 years. Seven cases had undergone multiple previous surgeries, while six patients had neurofibromatosis. The mean follow-up period was 5.8 ± 3.4 years. The average American Orthopaedic Foot and Ankle Society score improved from 47.5 ± 7.6 preoperatively to 78.9 ± 8.9 at the latest follow-up. Fifteen cases realized union, while one case saw persistent non-union occurred. Clinical results were excellent in one patient, good in seven cases, fair in six and poor in two cases. Radiological results were excellent in one patient, good in seven cases, fair in seven and poor in one case.


A 10-year retrospective review was conducted to identify organisms cultured in gas-producing foot infections in patients that presented to a large academic medical center and to note the prevalence of sepsis in this population upon presentation and patient outcomes at discharge. Seventy surgical cases satisfied inclusion criteria following a retrospective chart review of 207,534 procedures. Staphylococcus aureus, Group B Beta Streptococcus and Enterococcus species were the most common organisms growing in operating room cultures. Sepsis was present in slightly more than half the population, and 64 percent of patients underwent amputation after two or more surgeries, on average. One patient died. The authors concluded that gas-producing infections are mainly polymicrobial infections, seldom caused by Clostridium perfringen, that merit surgical exploration for optimal results.

Practice Management

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A study published in Mayo Clinic Proceedings analyzed 10 years of data from a nationwide survey of US physicians to confirm that burnout rates have climbed to alarming levels. Results indicate that 63 percent of physicians surveyed reported at least one burnout symptom at the end of 2021 and the start of 2022, up from 44 percent in 2017 and 46 percent in 2011. Just 30 percent of respondents felt satisfied with their work-life balance, down from 43 percent five years earlier. In 2020, 38 percent of respondents disclosed one or more symptoms of burnout while 46 percent reported a satisfactory work-life balance. Burnout has been associated with higher rates of alcohol abuse and suicidal ideation, in addition to increased medical errors and worse patient outcomes.

The early stages of the pandemic did not affect doctors equally: although emergency physicians and family physicians worked around the clock, constantly exposed to COVID-19, many clinicians in other specialties could reach patients through telehealth appointments and devote more time to their families. The study also suggested some doctors were more susceptible to burnout, including emergency medicine physicians, family medicine physicians and pediatricians. Stanford University's Tait Shanafelt said the increase in burnout is likely driven by both new problems and old problems that have exacerbated.


Strategies that medical practices should follow to best defend against malpractice claims include having the best insurance policy, developing patient-communication strategies and following the right steps in the event of litigation. Attorney Christopher Ryan says the least costly malpractice insurance policy is not always the best, and physicians should look for insurance that includes value-adding risk management tools. Senior trial attorney Tom Benvenuto adds that physicians should ensure they have a policy with an admitted carrier in their state. He also recommends fostering a sensitive, responsive bedside manner to help prevent a common cause of malpractice complaints. Benvenuto further urges the avoidance of communication problems, which Healthcare Risk Advisors' Peter Kolbert says can be facilitated by closed loop communication. He also recommends that physicians make an effort to improve patients' understanding at the outset of the doctor-patient relationship.

Kolbert says it is critical that physicians understand the subtleties of informed consent, while avoiding poor documentation in the electronic health record is also essential. He advises physicians to always chart issues of patient nonadherence. Should a lawsuit be filed, experts recommend that physicians consult with a lawyer immediately through their insurer. They should also prepare themselves rigorously for deposition or pretrial statement.


A sequential mixed methods study identified strategies that contribute to facilitator effectiveness. Analysis of data from the EvidenceNOW quality improvement (QI) project focused on seven regional cooperatives employing 162 facilitators to work with 1,630 small or medium-sized primary care practices. Facilitators were deemed more effective if at least 75 percent of their practices improved on at least one outcome measure (aspirin use, blood pressure control, smoking cessation counseling [ABS] or practice change capacity) from baseline to follow-up. Facilitators were less effective if less than 50 percent of their practices improved on these outcomes. Practices with more effective facilitators had a 3.6 percent improved change in the mean percentage of patients satisfying the composite ABS measure versus those working with less effective facilitators.

More effective facilitators also fostered motivation by customizing QI work and resolving resistance, guided practices to think critically and instilled accountability to support change, used these strategies together and described their work in detail. Less effective facilitators rarely applied these strategies and described their work in general terms. There were no differences in background, experience and work on documentation between more and less effective facilitators.


CARR, Inc. CEO Colin Carr writes that practices should prepare a monthly lease renewal negotiation strategy that seeks to cut overhead and improve cashflow and profitability. He advises against requesting a proposal from the landlord. Otherwise, "You're making it clear that you haven't hired an expert agent advising you and handling the process," he explains. "And you're allowing the landlord to set the tempo, signaling that you're likely willing to accept inferior terms." A better tactic is to hire an expert commercial real estate adviser to ensure the negotiation yields the best advantage for the tenant. That adviser "will protect you, put your interests first and ensure you're not taken advantage of during lease renewal negotiations," Carr writes. "Bottom line, your adviser should always be the party who submits the first offer."

Health Policy and Reimbursement

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The US Centers for Disease Control and Prevention no longer recommends universal masking in healthcare settings, unless they are in areas of high coronavirus transmission. The updates are part of an overhaul to the agency's infection control guidance for health workers, which "reflect the high levels of vaccine-and infection-induced immunity and the availability of effective treatments and prevention tools." The CDC now permits facilities in regions without high transmission to "choose not to require" masking by all doctors, patients and visitors. Approximately 73 percent of the country is currently seeing "high" rates of transmission, including just 7 percent of counties; the risk in nearly 62 percent of counties is considered low. The new guidance also lists exceptions when people might choose to mask, whereas the previous guidance had exceptions when masking was not recommended. Even in places without a universal masking requirement, if a provider works in a part of the facility seeing a COVID-19 outbreak, or if they care for immunocompromised patients, masks should be worn.


The US Centers for Medicare and Medicaid Services (CMS) announced that Part B premiums for Medicare beneficiaries will decrease next year by $5.20, amounting to a standard monthly premium of $164.90. A 14.5 percent increase in Part B premiums was imposed this year, which raised the monthly payments for those in the lowest income bracket to $170.10, compared to $148.50 last year. The hike was mainly driven by a projected jump in spending due to Aduhelm, a drug for Alzheimer's disease, although its manufacturer has since slashed the medication's price and CMS has limited coverage. The annual deductible for Medicare Part B beneficiaries will fall by $7 to $226 in 2023. Meanwhile, cost-sharing will be capped at $35 for a one-month supply of covered insulin starting July 1, and beneficiaries who take insulin through pumps supplied through the durable medical equipment benefit will not be charged a deductible.

Medicine, Drugs and Devices

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A new trial of esmolol hydrochloride gel indicates that it is safe and effective for treating diabetic foot ulcers. Prior phase 1/2 data showed that 60 percent of ulcers completely closed with esmolol versus 39 percent with standard of care; this encouraged the phase 3 randomized, double-blind placebo-controlled study across 27 sites in India. The percentage of participants achieving target ulcer closure at 12 weeks with esmolol combined with standard of care was around 60 percent, compared with just over 40 percent among those receiving only standard of care. Esmolol is currently authorized by the US Food and Drug Administration for cardiac indications only.


A registry study in the Danish Achilles tendon Database was held to assess various treatment outcomes of orthosis for acute Achilles tendon rupture in the first three weeks of treatment. The researchers compared patients treated with cast and walker. The study included 1,304 patients. Adjusted mean difference Achilles tendon Total Rupture Score was 0.1 after one year, 2.0 after six months and 3.0 after two years. The Heel Rise Height difference was 0.6, the Achilles Tendon Resting Angle difference was 0.03 degrees and the re-rupture odds ratio was 0.812. There were no relevant differences in treatment outcomes between cast- and walker-treated patients.


The US Food and Drug Administration (FDA) has issued new guidance dictating how it will enforce the 21st Century Cures Act, a 2016 law that blocks oversight of health software tools. In the document, the regulator signals its intent to regulate certain artificial intelligence (AI) tools that scrutinize images, vital sign patterns and other physiological information for signs of anomalies or risk of a particular condition. As an example, FDA plans to review sepsis alerts, among other algorithms that have enjoyed hands-off status. It has become increasingly concerned that allowing the tools to go unchecked could foster overdependence on products that point providers — sometimes inappropriately — to a specific clinical action. STAT investigations show that one widely used sepsis alert system from Epic Systems has generated many false alarms and resulted in treatment being initiated before the mistake was discovered. While FDA may not go as far as requiring developers to seek approval before bringing medical AI resources to market, some experts say the new guidance could result in improved product labels and/or compel vendors to provide more information about their algorithms and how they are relevant to clinical decision-making. Medical device attorneys counter that FDA is overstepping by attempting to regulate software that Congress has exempted from oversight.