News From ACFAS

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Don’t wait any longer! Register today and save up to $100 on your ACFAS 2023 registration.

ACFAS 2023 will be held February 9-12 in the LA LIVE entertainment complex. Kick off ACFAS 2023 a day early on February 8 with a new lineup of pre-conference workshops!

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.

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!

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.

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.

Residents Day
Pick up tips from the experts as you complete your post graduate education. Bundle with Coding Fundamentals for a full day of education!

Residency Directors Forum
Geared to assist resident educators in optimizing their resident review and oversight.

Earn up to 34 CECH and connect with over 2,000 of your colleagues at the premier event for foot and ankle surgeons. We can’t wait to see you there! Register now. On Monday, ACFAS eligible voting members received an email from the College’s independent election firm (acfas.ballot@intelliscaninc.net) with a unique link to the 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.

Two more reminder emails will be sent to you before the election closes on December 14, 2022. If your email system blocked the test email from our election company, your voting instructions were sent by US mail. If you are having difficulty voting, please contact our election company, Intelliscan, directly at kwier@intelliscaninc.com.

Please visit acfas.org/nominations for more information. The ACFAS team is learning about the work you do from a different angle – by visiting ACFAS members on the job!

Spending time in the field allows us to gain a better perspective and understanding of the medical and surgical care ACFAS members provide to their patients. By seeing the bigger picture, we are able to better support you and meet your needs.

A sincere thank you to Eric Barp, DPM, FACFAS; Brian Burgess, DPM, FACFAS; Randy Dei, DPM, FACFAS and Jeeten Singha, DPM, FACFAS for allowing the ACFAS team to shadow and learn from you. We look forward to continuing this learning experience to better meet your needs in the future. We're looking for the latest advances in cutting-edge surgical techniques for correction of foot and ankle disorders for Foot & Ankle Surgery: Techniques, Reports & Cases (FASTRAC), the College’s open access journal.

FASTRAC’s streamlined submission process allows foot and ankle surgeons around the world to stay up to date on the best clinical practices. You can also help shape the profession by becoming a FASTRAC peer reviewer.

Visit acfas.org/FASTRAC for more information and to submit your research.

Foot and Ankle Surgery

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Researchers retrospectively examined radiographs with novel radiographic techniques to determine how height changes from preoperative to postoperative radiographs following tibiotalocalcaneal arthrodesis (TTCA). Patients were divided into cohorts using Charcot, arthritis and pes planus as the indication for surgery, and Charcot and arthritis had an average decrease in height on anterior and posterior measurements of the height from the distal tibia to the calcaneus, while pes planus saw an increase in height. The median Charcot change in height was -12.0 ± 24.4 millimeters (mm) anteriorly and -7.6 ± 15.5 mm posteriorly. The average change in height for the arthritis cohort was -6.9 ± 6.7 mm anteriorly and -3.8 ± 5.8 mm posteriorly, and the pes planus group experienced an average increase in height of 0.5 ± 8.0 mm anteriorly and 2.9 ± 5.8 mm posteriorly. The authors advise surgeons who perform TTCA to be cognizant of the potential change in height to better individualize surgical and postoperative care.


A study was held to compare the functional outcomes of all-inside arthroscopic anterior talofibular ligament (ATFL) repair using a loop suture and/or a free-edge suture configuration in 71 patients with chronic lateral ankle instability (CLAI). Thirty-six patients underwent all-inside arthroscopic ATFL repair with loop suture while 35 underwent repair with free-edge suture (35) from February 2016 to July 2018. No postoperative wound complications, implant reactions or neurological or vascular injuries ensued. Both cohorts saw similar postoperative hospitalization, visual analogy scores, American Orthopaedic Foot and Ankle Society scores, Karlsson Ankle Functional Scores, Active Joint Position Sense and time of return to sport. Better Anterior Talar Translation was realized in patients with loop suture configuration because they needed a longer procedure time.


Researchers enlisted participants between 18 and 65 years with isolated Weber B, AO (Association for the Study of Internal Fixation) type 44B ankle fractures and minimal talar shift from 22 Australian and New Zealand hospitals for the Combined Randomized and Observational Study of Surgery versus No Surgery for Type B Ankle Fracture Treatment (CROSSBAT). The authors sought to ascertain whether surgery is superior to nonsurgical management for treating fractures after a minimum follow-up of five years. Of the 160 randomized patients included in the study, 77 were tracked for repeat analysis at minimum five-year follow-up. Surgery was not tied to clinically or statistically significant differences in this group compared to nonoperative management for the American Academy of Orthopaedic Surgeons Foot and Ankle Outcomes Questionnaire or the physical component summary of the SF-12v2 General Health Survey. A higher rate of adverse events was noted in the group that underwent surgery.

Practice Management

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Practices have a number of options for unsecured financing, with unsecured lines of credit considered ideal for covering unexpected costs, funding growth initiatives and providing a cash flow buffer or access to working capital. Business credit cards function similarly to lines of credit, but tend to have higher rates and lower credit limits. They are favorable for covering day-to-day costs and establishing business credit. Merchant cash advances are viewed as ideal for underwriting growth initiatives, for practices with large numbers of card transactions and lower credit and practices requiring flexible working capital. Finally, invoice factoring can provide working capital by leveraging unpaid invoices, and accommodate practices that have long accounts receivable periods and large invoice amounts.


Medicare's Acute Hospital Care at Home program, which offers patients an alternative for in-hospital medical care, was ramped up significantly because of the COVID-19 pandemic. Medicare officials in November 2020 announced that, while the federally declared public health emergency was in effect, hospitals could apply for a waiver of 24/7 on-site nursing care requirements, and approved facilities would receive the same remuneration for hospital-at-home care as for in-hospital care. Medicare has granted waivers to 256 hospitals in 37 states since then, but the prospect of wider adoption is muddled due to uncertainty over future participation. The public health emergency expires in January, and 27 percent of programs that participated in a Hospital at Home Users Group survey said they were likely to discontinue hospital-at-home care without a waiver, while 40 percent were unsure and 33 percent were likely to maintain the program. A bill proposed in the House of Representatives to extend the program for two years after the emergency's ending failed to advance, although supporters think similar legislation could pass. Medicare could also allocate a multisite demonstration project to keep some hospital-at-home programs operational.

Health Policy and Reimbursement

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The US Department of Health and Human Services (HHS) announced that close to 3.4 million people so far have enrolled in 2023 coverage through the Affordable Care Act marketplace, up 17 percent from the same period a year ago. Since the open enrollment period began November 1, there have been over 665,000 new enrollees in marketplace plans. New enrollees' demographic details were not released, but HHS Secretary Xavier Becerra said, "There's a very strong chance we’re continuing to get communities that had been left behind to sign up."


Ninety federal audits reveal millions of dollars in overcharges and other errors in payments to Medicare Advantage health plans, with some overbilling the government more than $1,000 per patient annually on average. The audits exposed about $12 million in net overpayments for the care of 18,090 patients sampled, although this figure is likely conservative. The US Center for Medicare and Medicaid Services' (CMS) plans to unveil a final payment error rate extrapolation rule to recoup those overcharges on Nov. 1 was postponed until February. Ted Doolittle, formerly with CMS' Center for Program Integrity, said the agency seems be "carrying water" for the insurance sector, which is "making money hand over fist" off Medicare Advantage plans. Insurers' opposition to extrapolation has discouraged its application by CMS officials, while critics say CMS audits only a small portion of Medicare Advantage contracts nationally and should more aggressively protect tax dollars.


Attorneys general from 22 states have filed a petition under the Administrative Procedures Act requesting that the US Centers for Medicare and Medicaid Services (CMS) and the US Department of Health and Human Services repeal the mandate requiring all patient-facing healthcare workers to receive full COVID-19 vaccination and any related guidance. "Evidence available at that time, and evidence that has emerged since, demonstrates that full vaccination doesn't prevent infection or transmission," stated coalition head and Montana AG Austin Knudsen. "Breakthrough infections are common, and studies increasingly show heightened health risks associated with the vaccines." Knudsen further contended that the still-in-effect "mandate has limited many patients' access to needed medical care and imposed substantial costs on patients and healthcare workers without any corresponding benefits."

Medicine, Drugs and Devices

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California Attorney General Rob Bonta wants to probe racial discrimination in healthcare, including through an investigation of software programs and decision-making algorithms hospitals use to treat patients. In August, he requested 30 hospital CEOs to provide a list of the commercial software programs their facilities use to support clinical decisions, schedule operating rooms and direct billing practices in return for confidentiality. Bonta said the goal is to detect algorithms that may divert more attention and resources to white patients than to minorities. He is soliciting hospitals' cooperation in his algorithm probe by defining racial and ethnic disparities as injustices in need of intervention, saying the inquiry falls under the California Department of Justice's responsibility to safeguard civil rights and consumers.


The US Food and Drug Administration (FDA) is investigating the risk of severe hypocalcemia with serious outcomes, including hospitalization and death, in patients with advanced kidney disease on dialysis treated with the osteoporosis medicine denosumab. The agency's review of interim results from an ongoing safety study of the drug suggests an increased risk of hypocalcemia in patients with advanced kidney disease. Preliminary results from a separate internal FDA study further investigating hypocalcemia in dialysis patients treated with denosumab show a substantial risk with serious outcomes, including hospitalization and death. Because of the frequency and seriousness of these risks, the agency is alerting healthcare professionals and patients about them and that it is continuing to evaluate this potential safety issue with denosumab use in patients with advanced kidney disease, particularly those on dialysis. The drug was first approved to treat postmenopausal women with osteoporosis at high risk for bone fracture and later approved to treat men with osteoporosis, glucocorticoid induced osteoporosis, bone loss in men receiving androgen deprivation therapy for prostate cancer and in women receiving aromatase inhibitor therapy for breast cancer. FDA will communicate its final conclusions and recommendations when it has completed its review or has more information to share.


MRI has shown that taking nonsteroidal anti-inflammatory drugs (NSAIDs) for osteoarthritis may actually make inflammation in the knee joint worse, according to research scheduled for presentation at the annual meeting of the Radiological Society of North America. The findings highlight the need to reconsider how best to manage osteoarthritis symptoms, noted a team led by Johanna Luitjens, MD, of the University of California, San Francisco. "On the one hand, the anti-inflammatory effect that normally comes from NSAIDs may not effectively prevent synovitis, with progressive degenerative change resulting in worsening of synovitis over time," said Luitjens. "On the other hand, patients who have synovitis and are taking pain-relieving medications may be physically more active due to pain relief, which could potentially lead to worsening of synovitis, although we adjusted for physical activity in our model."


The Utah Bionic Leg created by researchers at the University of Utah could help people climb stairs and inclines, using mechanical levers. The researchers designed the prosthesis for people missing a leg from above the knee, with two separate modules that each feature a controller and battery. The knee module perceives the amount of power needed, then adjusts the motor's output up or down as required. The leg also sports an ankle joint and a big toe to provide stability and more natural walking. The appendage taps the power of smaller motors to accommodate speed and strength, internally altering the joint's geometry and the point at which the motor's power is impelled.