News From ACFAS

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As the COVID-19 situation continues to change each day, ACFAS would like to remind members we’re in this together. We are here to provide you with resources and answer questions that may arise during this unprecedented time.

To keep you informed, the College has created a COVID-19 Resources Page. This centralized page includes ACFAS resources you may need to reference to help you in your practice, including, position statements, practice management tip sheets, information on ACFAS OnDemand, tips for communicating with your patients and information for students and residents to access ACFAS online resources.

Visit acfas.org/COVIDResources to access this valuable information. Check back regularly—this page will be updated as more information becomes available. If you have any questions or need further assistance, don’t hesitate to contact an ACFAS team member. Congress is working quickly to pass legislation that would provide financial assistance to airlines, financial markets, small businesses and hospitals. Under S. 3548, the third coronavirus aid package, there are small business measures that could help foot and ankle surgeons with the challenges they face as a result of this pandemic.

According to Politico analysts, “S. 3548 would aim to maintain cash flow to small businesses by providing 100 percent federally guaranteed loans to employers with less than 500 employees who maintain their payroll during the public health emergency caused by the coronavirus. The legislation would appropriate $300 billion to expand the Small Business Administration’s existing 7(a) loan program to cover payroll support, such as paid sick leave, from March 1 through Dec. 31, 2020. The language is retroactive to March 1 to allow employers who have already laid off employees to bring them back on to payroll.

Under the expansion, employees with fewer than 500 people would be eligible to receive loans up to $10 million through SBA-certified lenders, like banks, to supplement payroll, mortgage, debt and other expenses associated with continuing to pay their employees’ salaries. It would also increase the cap on SBA Express loans from $350,000 to $1 million and reduce associated fees for borrowers and lenders to ease participation.”

Congress also gave $100 billion in emergency funding to hospitals bracing for coronavirus under the massive stimulus package late last night.

A vote is likely to take place Wednesday evening.

When ACFAS has the opportunity to sign joint letters to Congress or participate in grassroots advocacy, we will get engaged. For now, ACFAS is monitoring the legislation. We are also in close contact with advocacy and lobbying efforts at APMA and will keep you apprised as this evolves. In this challenging time of the COVID-19 situation, ACFAS is offering members Practice Management and TeleHealth recommendations in two new guideline documents to help keep patients and staff healthy while still providing care.

These guidelines include:

• clinical triage—dealing with symptomatic patients and limiting entry of germs
• practice cleanliness
• managing practice volume to minimize patient-to-patient contact
• TeleHealth basics

Along with staying informed through ACFAS resources, it is also important to regularly review the CDC guidelines and to check with your state and/or federal government and insurance carriers for specific rules or regulations in providing care and coverage.

Both of these tip sheets can be downloaded, along with other valuable COVID-19 resources at acfas.org/COVIDResources. In response to the rapidly growing health concerns and challenges amid COVID-19, ACFAS released a position statement following guidelines put forth by the American College of Surgeons (ACS).

The newly released position statement COVID-19 and Non-Emergent Surgical Procedures, calls for medical practices to halt “elective” surgeries. These guidelines implore hospitals to consider patient and staff medical needs as well as their capacity to meet those needs, to consider capacity and feasibility for procedures given current hospital and community limitations as well as assessing risks to a patient if surgery is delayed.

ACFAS supports the direction taken by ACS and the Centers for Disease Control and Preventions (CDC). For more information and to read the full statement, visit acfas.org/COVIDResources. The current COVID-19 pandemic has created many challenges for our professional community, including DPM candidates in podiatric medical schools, residents working to complete their education in CPME-approved residency programs and post-graduate fellows in their final weeks of fellowship. The College is committed to supporting our community and helping to ease the pressures facing our students and residents during this time.

To help fill the educational void, the College has made ACFAS OnDemand learning resources available to students and residents through the end of the residency/school year at no cost. The College, along with CPME, ABFAS and AACPM/COTH, are committed to working together to overcome these obstacles and ensure the next generation of foot and ankle surgeons remain healthy and on the right path to reaching their educational goals.

Foot and Ankle Surgery

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The study looked at the relationship between pain and angular change of the lower extremity in genu varus patients. Researchers evaluated standing whole-lower-leg plain radiographs of 127 legs with >4 degrees of genu varum, assessing pain separately at the ankle, forefoot and hindfoot and measuring knee, ankle and subtalar joint angles. Patients were divided into three groups according to whether they had mild, moderate or severe lower leg angular imbalance. The presence of multiple pain locations differed significantly between group and was significantly higher in the severe group than in the mild group. Likewise, the subtalar angle was significantly more varus in the severe group than in the mild group.


The study measured limitations in sagittal ankle range of motion (ROM) at least two years after lateral column lengthening osteotomy of the calcaneus (LLC) and their implications for quality of life. Ankle joint complex ROM in plantarflexion and dorsiflexion was measured bilaterally using a goniometer and fluoroscopy, while quality of life was assessed using the short-form health questionnaire (SF36). ROM of the ankle joint complex on the affected side for patients was smaller than on the contralateral side and in healthy persons. Among patients, SF36 total and pain scores correlated with ROM of the subtalar joint. Patients and healthy persons with smaller dorsiflexion had lower quality of life scores. Researchers conclude that ROM should be considered in the treatment and rehabilitation planning in patients who are candidates for LLC.


The study retrospectively analyzed 29 patients treated with an Ilizarov ring fixator for Charcot arthropathy to determine whether this measure leads reliably to walking ability. Two authors separately assessed radiologic fusion at final follow-up on conventional X-rays. The association between walking ability and the presence of osteomyelitis at the time of reconstruction, and the presence of fusion at final follow up was investigated using Fisher's exact test. Ten patients (34.5 percent) reached fusion, but 19 did not (65.5 percent), and two patients needed below-knee amputation. Twenty-six of the remaining 27 patients maintained walking ability, 23 of those without assistive devices. Walking ability was independent from the presence of fusion and the presence of osteomyelitis at the time of reconstruction. The authors say their findings encourage limb salvage and deformity correction in Charcot arthropathy, even with underlying osteomyelitis.

Practice Management

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Independent physicians need to brace themselves for the financial fallout of COVID-19. Owners should make sure their practice is up to date on the status of COVID-19 and its impact on their community of patients, which requires active and careful monitoring as the situation is changing quickly. Practices should use all means to communicate with patients, including social media, the practice website and the practice portal. Physicians should also review their procedures and policies regarding illness and disability to ensure that sick employees do not come into work. Telemedicine may be an option for some practices under the Coronavirus Preparedness and Response Supplemental Appropriations Act, which has relaxed the restrictions on physicians being able to offer telemedicine. Senior physicians may be impacted medically by COVID-19, and practices need to have some kind of succession or continuity plan in place to account for this.


Starting Tuesday, staff at Indiana University (IU) Health Physicians are calling patients scheduled for routine care appointments to come in at a later date, hoping to mitigate the spread of the novel coronavirus and protect its workforce. Limited testing is a recurring issue for patients and practices. Practices in rural areas are often the only source of healthcare for their community, but they lack the personal protective equipment needed for testing. Telehealth is also becoming a vital way to deal with testing and supply concerns. IU Health Physicians is currently bringing on more than 100 physicians this week to its telehealth platform to mitigate in-person visits across its sites. Over the past few weeks, primary-care provider ChenMed has shifted care for most its Medicare Advantage patients from clinic visits to telehealth or home visits in order. The US Centers for Medicare and Medicaid Services announced that Medicare will reimburse for telehealth services at the same rate as regular in-person visits.


Independent practices need to have disciplined and efficient revenue cycle management (RCM), especially given the rising costs of operating a practice. As RCM becomes more demanding, many practices are turning to vendors to handle all or part of the process, but many are not. One Wisconsin independent practice employs 11 back office personnel, including coders and billing and payments specialists, and managers say the team saves money by performing at a very high level despite the associated overhead. The practice is also proactive with patients, obtaining payment upfront whenever possible and frequently educating patients about their insurance. Another practice, which has done its own RCM for 37 years, says it might save money by outsourcing RCM but worries that introducing a third party would hurt long-standing patient relationships in the rural communities it serves.

Health Policy and Reimbursement

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Clinical training has become the latest casualty of the coronavirus, also known as COVID-19. College campuses around the country have already sent students home, while hospitals, nursing homes and other healthcare facilities have canceled clinical rotations for student nurses. Officials say the goal is to protect patients and preserve medical supplies. However, medical educators say the canceled programs won't get the direct care experience that is required to graduate on time. As a result, this could potentially slow the pipeline of new healthcare workers at a time when they may be needed the most. Some private nursing schools have been advocating for more simulation training. They say it has advanced to the point that it is just as effective as training in a hospital or clinic.


Medicare said it would immediately expand coverage for telemedicine nationwide to help seniors with health problems stay home to avoid the coronavirus. The new option will allow millions of older people to take care of ongoing medical problems as well as new concerns while heeding public health advice to stay home during the outbreak. Risk of serious illness from the coronavirus is greater for older people and those with underlying health problems such as lung conditions, diabetes or heart problems. Many Medicare beneficiaries are managing chronic health issues that put them at heightened risk. The telemedicine expansion is geared directly to this vulnerable group. Telehealth coverage under traditional Medicare was previously limited, mostly available in rural areas at designated sites. Medicare's recent announcement allows clinicians and hospitals to bill Medicare for visits via telemedicine that previously had to take place in person, at a medical office or facility.


Connecticut, Maryland, Massachusetts, Nevada, New York, Rhode Island and Washington state are allowing residents to sign up for health coverage during special enrollment periods (SEPs) in response to COVID-19. Enrollment deadlines range from April 2 through April 25. California already had a SEP in place for residents who say they were unaware of a new state health coverage requirements and new state subsidy help; that SEP ends April 30. The District of Columbia also has had a SEP in place for residents who learn about the district's new health coverage requirements. For taxpayers who file their 2019 income taxes by April 15, the deadline for that SEP is April 15. In all states, people can still sign up for Affordable Care Act coverage outside the regular open enrollment period if they qualify for a SEP due to a life event such as the loss of employment-based health insurance or a move to a new state. Other states have asked the US Department of Health and Human Services and health insurers to create a COVID-19-inspired open enrollment period for residents of HealthCare.gov states.

Medicine, Drugs and Devices

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The coronavirus outbreak has led to shortages of personal protective equipment (PPE), fueling fear and frustration among medical staffers. In addition to their own stockpiles, hospitals and health centers can draw from the Strategic National Stockpile, a federal store of masks, medicine and medical equipment but the outbreak has strained supplies. Many health systems are launching protocols to conserve their limited supplies even as staff that do not normally need masks are now being asked to wear them. Some health workers are taking the matter into their own hands, asking for donations on social media and stocking their own PPE from a makeshift community stockpile.


Two recent studies find that coronavirus can persist on inanimate surfaces but disagree on how long they can live on glass, metal or plastic. A study in the Journal of Hospital Infection found that the virus can live up to nine days, while a pre-print study in the databse medRxiv said the virus can stay viable in the air for up three hours, on copper for up to four hours, on cardboard for up to 24 hours and on plastic and stainless steel for two to three days. The medRxiv study compares COVID-19 to SARS-CoV-1 and find that the viruses have similar environmental viability, suggesting that this is not behind COVID-19's greater transmissibility. This also implies that, like SARS-CoV-1, COVID-19 may be associated with superspreading, in which a single infected person generates a large number of secondary cases. Both studies agreed that the virus can be inactivated by surface disinfection procedures with 62-71 percent ethanol, 0.5 percent hydrogen peroxide, or 0.1 percent sodium hypochlorite.


Stevens Institute of Technology researchers have developed a smart insole powered by artificial intelligence (AI) that analyzes a person's gait in real time when worn in their shoe. Stevens Wearable Robotic Systems Laboratory director Damiano Zanotto and colleagues designed the SportSole to monitor its movement and spatial orientation with accelerometers and gyroscopes, while force sensors detect plantar pressure. The SportSole makes 500 readings each second, and Zanotto condenses those measurements within a few key features and sends the results to an AI algorithm to derive gait parameters accurate to within a few percentage points. The SportSole also operates if the wearer is walking or running and does not require customization for individual users. Zanotto said, "We're achieving the same or better results [as high-end sensors] at a far lower cost, and that's a big deal when it comes to scaling this technology."