The Ledger.

Every implant in a podiatric surgeon's hand was designed, manufactured, marketed, and — usually — first taught by industry. Every cadaver lab the resident scrubs in for is paid for, in part, by industry. Every conference where techniques are debated runs on industry exhibitor revenue. Every fellowship in foot and ankle exists in some financial proximity to it. The relationship is not incidental. It is the substrate of modern practice.

That is the first true thing. The second is harder. The same relationship that produces the locking plate, the headless compression screw, the PEEK fixation, the 3D bunion correction system has also produced a Medicare wound-care fraud docket so dense the DOJ now runs a dedicated Wound Care Initiative — and disclosure-discrepancy literature so consistent across orthopedic subspecialties that one third of authors at major meetings routinely fail to report what industry has already told the federal government about them.

The Physician Payments Sunshine Act, embedded in the 2010 Affordable Care Act, requires drug and device manufacturers to report any single payment over $10 — or any aggregate annual payment exceeding $100 — to physicians, including doctors of podiatric medicine. CMS publishes the data each June through the Open Payments database. Patients, journalists, and any podiatric resident with an internet connection can search any DPM by name.

Open Payments solved the problem of recording physician-industry transfers. It did not solve the problem of using that record to inform research, education, or guideline development. Multiple studies have compared physician-reported disclosures at meetings and in publications against the federal Open Payments record. The discrepancy rates are not encouraging.

Most discrepancies fall below $1,000 per item. Most are likely careless rather than concealing. But "careless" is a structural problem, not an individual one. When a third of senior authors at the largest orthopedic meeting in the country fail to align their disclosures with what their own consulting agreements have already documented federally, the integrity of the resulting literature is exactly as good as the disclosure system. That is the system's floor, not a worst case.

The clearest contemporary illustration of what industry-physician misalignment looks like at scale is the skin substitute market — cellular and tissue-based products applied to chronic wounds, including diabetic foot ulcers and venous leg ulcers. Roughly 75 products on the market. Many launched at high prices through 510(k) or §361 HCT/P pathways with thin or absent comparative-effectiveness data. The Average Sales Price + 6% reimbursement structure created an incentive aligned almost perfectly with using the highest-priced product available.

In the CY 2026 Physician Fee Schedule final rule, CMS reclassified most skin substitutes from biologics (paid at ASP+6%) to "incident-to supplies" at a flat national rate of $127.28 per square centimeter. The agency projects roughly 90% reduction in skin substitute program spending — approximately $19.6B in savings for 2026 alone. ⚠ verify LCDs were withdrawn in late December 2025 even as the payment rule moved forward. The flat-rate fix may simply migrate the fraud risk from price arbitrage to overutilization.

The skin-substitute story is about fraud at the edges of the profession. The bunion story is about something different — what happens when a single company successfully redefines a procedure faster than the literature can keep up. Treace Medical Concepts, founded in 2014, built its identity around the Lapiplasty 3D Bunion Correction System. By 2021, Treace was a publicly traded company (NASDAQ: TMCI). Surgeon adoption was driven by industry-organized training, branded technique, and a coordinated marketing apparatus that few academic departments could rival.

The clinical question — whether tri-planar Lapidus bunionectomy outperforms appropriately-selected distal osteotomy or modified MIS techniques across age, deformity severity, and recurrence — remains genuinely open. The literature is improving but heavily populated by surgeons with industry relationships to one or another platform. ⚠ verify Long-term comparative outcome evidence is lower than the marketing positioning suggests, on every side of the question. The structural lesson: the speed of industry diffusion routinely outruns the speed of independent evaluation — and the profession's tools for that evaluation are themselves industry-funded more often than not.

Residents are not formally covered recipients under the Sunshine Act — but they enter a learning environment in which their attendings are. Mentor-to-trainee transmission of practice patterns is the entire point of residency. This is not framed as a critique. It is framed as a warning: the resident who never thinks about this is, by default, downstream of decisions made by people they have never met. The work for the trainee is to develop a stance — neither hostile to industry nor captured by it — early enough that it becomes a habit rather than a posture.

This last point is worth dwelling on. Most published Open Payments analyses in foot and ankle have used orthopedic surgeons as the unit of analysis, not podiatric surgeons specifically. There is a real research gap here for any DPM analyst willing to do the work.