Foot and ankle experience in orthopaedic residency

Ankle Arthroscopy Procedural Volume Is Low Among Graduating Orthopaedic Surgery Residents

Purpose

To evaluate graduating orthopaedic resident case volume and variability for ankle arthroscopy from 2016 to 2020.

Methods

The Accreditation Council for Graduate Medical Education surgical case log data from 2016 to 2020 for graduating United States orthopaedic surgery residents was assessed. Arthroscopy procedures of the leg/ankle were categorized. The average number of cases performed per resident was compared from 2016 to 2020 to determine the percent change in case volume. The 10th, 30th, 50th, 70th, and 90th percentiles of case volumes from 2016 to 2020 were presented to demonstrate case volume variability.

Results

There was no significant change in the average number of leg/ankle arthroscopy cases from 2016 to 2020 (6.2 ± 5 [range 0-35] vs 6.1 ± 6 [range 0-76] P = .732), despite a 19% increase in the average number of total leg/ankle procedures performed over time (168.4 ± 47 [range 55-414] in 2016; 200.8 ± 57 in 2020 [range 67-601], P < .001). There was wide variability in ankle arthroscopy case volume among residents. The 90th percentile of residents performed 13 cases in 2020, compared with 5 in 50th percentile, and 1 in the 10th percentile.

Conclusions

Orthopaedic surgery resident exposure to ankle arthroscopy has remained low and highly variable overtime, despite an overall increase in the total number of leg/ankle procedures performed.

Clinical Relevance

Understanding ankle arthroscopy in case volume and variability is important for programs to ensure that orthopaedic residents are gaining adequate exposure to increasingly popular procedures. Orthopaedic surgery residency programs should explore methods to increase resident exposure to ankle arthroscopy.

Cross-Sectional Analysis of Foot and Ankle Questions on the Orthopaedic In-Training Examination: A Guide for Resident Preparation

Background:

The Orthopaedic In-Training Examination (OITE) is a standardized examination administered annually to orthopaedic surgery residents. The examination is designed to evaluate resident knowledge and academic performance of residency programs.

Methods:

All OITE foot and ankle questions from 2009 through 2012 and 2017 through 2020 were analyzed. Subtopics, taxonomy, references, and use of imaging modalities were recorded.

Results:

There were a total of 167 foot and ankle (F&A)–related questions across 8 years of OITE examinations. Trauma remained the most commonly tested subtopic of F&A across both subsets, followed by rehabilitation, tendon disorders, and arthritis. We found an increase in questions related to arthritis (P = .05) and a decrease of questions related to the diabetic foot (P = .02). Taxonomy 3 questions constituted 49.5% of F&A questions from 2009 through 2012 compared with 44.7% of questions from 2017 to 2020 (P = .54). Radiography was the most commonly used imaging modality in both subsets. From 2009 to 2012, 63.6% of questions included a radiograph compared with 76.5% in 2017 through 2020 (P = .13). FAI (Foot & Ankle International), JAAOS (Journal of the American Academy of Orthopaedic Surgeons), and JBJS (The Journal of Bone and Joint Surgery) were the most commonly cited journals, making up more than 50% of total citations. Citations per question increased from 2.20 to 2.42 from 2009-2012 to 2017-2020 (P = .01). The average lag time in the early subset was 8.2 years and 8.9 years in the later subset.

Conclusion:

This study provides a detailed analysis of the F&A section of the OITE. Use of this analysis can provide residents with a guide on how to better prepare for the OITE examination.

Level of Evidence:

Level IV, cross-sectional review of Orthopaedic In-Training Examination questions

Volume and Variability of Foot and Ankle Case Exposure During Orthopaedic Residency: 2014-2019

BACKGROUND

Exposure to a comprehensive breadth and volume of surgical cases is a fundamental component of orthopaedic education, though standardization of case exposures across residency programs is limited to a small amount of required case minimums. Significant variability in exposure to subspecialty cases, such as foot and ankle surgeries, can create distinctly different residency experiences.

METHODS

Accreditation Council for Graduate Medical Education (ACGME) surgical case logs from 2014 to 2019 for leg/ankle and foot/toes were examined following the 2013 implementation of case minimums. Average surgical case volume across subcategories and the average volume of different residency percentiles were analyzed to assess variability.

RESULTS

The mean total volume of case exposure for graduating orthopaedic residents has increased significantly since 2014 for both leg/ankle cases (28.6%) and foot/toes (27.8%), though totals were still down compared with when ACGME reporting began in 2007. Arthrodesis exposures have increased significantly for leg/ankle (69.2%) and foot/toes (93.8%) cases since 2014, and ankle arthroscopy has increased 20.7%. Disparities in total cases between 10th and 90th percentile programs have shown a nonsignificant decrease over time, with significant differences between leg/ankle arthrodesis (8-fold), leg/ankle arthroscopy (13-fold), and foot/toe arthrodesis (3.5-fold) in 2019.

CONCLUSION

The mean volume of foot and ankle case exposures among graduating residents has continued to rise since the implementation of case minimums in 2013 but disparities in volume are present, most notably concerning arthrodesis and arthroscopy. Recognition and future attention toward addressing this variability can be meaningful in promoting a more comprehensive, standardized orthopaedics education.

LEVEL OF EVIDENCE

Level III: Retrospective comparative study.

Variability in the Duration of Designated Pediatric Orthopaedic Rotations Among US Residency Programs

Our goal was to assess the variability in the assigned duration of pediatric orthopaedic rotation among US allopathic orthopaedic residency programs to see how pediatrics is incorporated into surgical education.

The Perception of the Scope of Practice of Podiatric Medicine in a Large Teaching Hospital Demonstrated by Internal Medicine Residents and Patients

BACKGROUND:

The scope of podiatric practice has changed significantly in the past couple of decades. Despite the increased quality of training, many people outside of podiatry may not realize what our scope of practice entails.

METHODS:

We conducted a survey consisting of 10 items and asked internal medicine residents at Rush University Medical Center and patients whether they would feel comfortable consulting podiatrists, or being treated for each issue.

RESULTS:

The results for residents are as follows: 1) toenail fungus, 35% yes and 65% no; 2) diabetic wound care, 87.5% yes and 12.5% no; 3) bunion surgery, 90% yes and 10% no; 4) ankle fracture surgery, 25% yes and 75% no; 5) calcaneal fracture surgery, 50% yes and 50% no; 6) tarsal tunnel nerve surgery, 62.5% yes and 37.5% no; 7) lower extremity arterial bypass, 5% yes and 95% no; 8) below-knee amputation, 5% yes and 95% no; 9) transmetatarsal amputation, 67.5% yes and 32.5% no; and 10) venous stasis wound care, 65% yes and 35% no. The results for patients are as follows: 1) toenail fungus, 72.5% yes and 27.5% no; 2) diabetic wound care, 70% yes and 30% no; 3) bunion surgery, 62.5% yes and 37.5% no; 4) ankle fracture surgery, 57.5% yes and 42.5% no; 5) calcaneal fracture surgery, 55% yes and 45% no; 6) tarsal tunnel nerve surgery, 50% yes and 50% no; 7) lower extremity arterial bypass, 32.5% yes and 67.5% no; 8) below-knee amputation, 27.5% yes and 72.5% no; 9) transmetatarsal amputation, 52.5% yes and 47.5% no; and 10) venous stasis wound care, 32.5% yes and 67.5% no.

CONCLUSIONS:

Internal medicine residents and patients do not have an accurate perception of the scope of podiatric medicine. This proves that, as a profession, we need to raise awareness about what the podiatric scope of medicine actually entails.

Foot and ankle questions on the orthopaedic in-training examination: analysis of content, reference, and performance

The purpose of this study was to provide a comprehensive analysis of the Orthopaedic In-Training Examination's (OITE's) questions, question sources, and resident performance over the course of residency training.The authors analyzed all OITE questions pertaining to foot and ankle surgery between 2006 and 2010. Recorded data included the topic and area tested, imaging modality used, tested treatment method, taxonomic classification, cited references, and resident performance scores. Foot- and ankle-related questions made up 13.9% (186/1341) of the OITE questions. Thirteen general topic areas were identified, with the most common being foot and ankle trauma, the pediatric foot, and foot and ankle deformity. Imaging modalities were tested in approximately half of the questions. Knowledge of treatment modalities was required in 58.1% (108/186) of the questions. Recall-type questions were the most common. Trends existed in the recommended references, with 2 journals and 1 textbook being commonly and consistently cited: Foot and Ankle International, The Journal of Bone and Joint Surgery American Volume, and Surgery of the Foot and Ankle, respectively. Resident performance scores increased with each successive level of training.An understanding of the topics and resources used for OITE foot and ankle questions is an important aid in creating or improving residency programs' foot and ankle education curricula. With knowledge of question content, source, and resident performance, education can be optimized toward efficient learning and improved scores on this section of the examination.

Foot and ankle experience in orthopedic residency: an update

BACKGROUND

In 2003, a limited survey regarding the number of dedicated foot and ankle faculty and foot and ankle rotations at orthopaedic surgery residency programs was published. The purpose of this paper was to update the results of that previous survey and provide additional, more in-depth information.

MATERIALS AND METHODS

A survey questionnaire was emailed to the program directors and chairpersons of the 150 ACGME-accredited orthopaedic residency training programs in the United States.

RESULTS

Responses were obtained from all programs. One hundred thirty-seven (91.3%) programs had one or more orthopaedic surgeon faculty members with a predominantly foot and ankle practice (at least 50%), an increase of 5.5 percentage points from the survey performed 6 years previously. One hundred forty three (95.3%) programs had one or more orthopaedic surgeon faculty members with a practice consisting of at least 25% foot and ankle. One hundred twenty programs (80%) had one or more dedicated foot and ankle rotations, an increase of 15.1% from 6 years prior. Orthopaedic surgery residents were felt to spend a mean of 30.4% and a median of 20% of their time with board-certified/ board-eligible orthopaedic surgeons in rotations that include treatment of foot and ankle pathology but were not considered ;;dedicated'' foot and ankle rotations.

CONCLUSIONS

The number of orthopaedic surgery residency programs with rotations and faculty members dedicated to foot and ankle education has increased over the 6 years between surveys. Orthopaedic surgery residents' experience and skill development in foot and ankle surgery during their 5 years of residency training are not limited to their time spent in dedicated foot and ankle rotations.

Orthopaedic surgery core curriculum: foot and ankle reconstruction

BACKGROUND

The purpose of this study was to develop a core curriculum for orthopaedic surgery and to conduct a national survey to assess the importance of 281 curriculum items. Attention was focused on 45 items pertaining to the foot and ankle.

METHODS

A 281-item curriculum was developed. A content review and cross-sectional survey of a random selection of orthopaedic surgeons with primary nonacademic affiliations was completed. Data were analyzed descriptively and quantitatively using histograms, modified Hotelling's T(2)-statistic, and the Benjamini-Hochberg procedure. Our analyses assumed that each respondent answered questions independently of the answers of any other respondent but that the answers to different questions by the same respondent might be dependent.

RESULTS

Of the 156 orthopaedic surgeons contacted, 131 (86%) participated in this study. Eighty-two percent (37 of 45) of the items were ranked by respondents with an average mean score higher than 3.5/4.0 and 42 higher than 3.0/40, thus suggesting that 93% of the items are important or probably important to know by the end of residency (p <or= 0.07).

CONCLUSION

This study demonstrated agreement on the importance of 93% of the items that pertain to foot and ankle reconstruction to be included in a core curriculum for orthopaedic surgery. The ability to make diagnoses and to manage common fractures, soft-tissue conditions, and arthritic conditions of the foot and ankle are very important for residents to know upon graduation from their residency programs. The exceptions to these are the ability to perform primary and revision arthroplasty of the ankle.

Using resident input to identify and integrate essential components of a foot and ankle rotation

BACKGROUND

Foot and ankle surgery is one of the orthopaedic subspecialties to which residents not uncommonly receive limited exposure. Therefore, it is important to identify what both faculty and residents regard as fundamental to a foot and ankle rotation. The purposes of this study were to identify the essential components of a foot and ankle rotation and to correlate these with the American Orthopaedic Foot and Society (AOFAS) core curriculum, and to discuss how to integrate resident input and AOFAS guidelines into a valued foot and ankle rotation.

METHODS

Over a 5-year period, each orthopaedic resident beginning a 10-week postgraduate year (PGY) 3 foot and ankle rotation was asked to choose topics to be covered during weekly 45-minute discussion conferences. Each resident also identified personal goals for the rotation. Data were collected in this prospective nature, and the responses of the 24 PGY 3 residents from our program who completed the rotation between February, 2000, and April, 2005, were analyzed. The discussion conference topics were compared to the AOFAS guidelines, and the top 10 personal goals were determined. Prerotation and postrotation Orthopaedic Inservice Training Examination (OITE) foot and ankle scores for the residents also were analyzed.

RESULTS

Among the nine AOFAS core curriculum categories, residents most frequently chose chronic soft-tissue foot and ankle problems, followed in frequency by foot and ankle arthritis, foot and ankle trauma, and diabetic foot. Individually, posterior tibial tendon insufficiency, hallux valgus, diabetic foot, and calcaneal fracture were the most frequently chosen discussion conference topics. In regards to personal goals for the rotation, residents most commonly wanted to improve their physical examination skills (88%) and increase their orthotic knowledge (71%). The OITE scores improved by a mean of 12% after the rotation.

CONCLUSIONS

This study provides new and detailed information about resident expectations for a valued foot and ankle rotation. These results should be integrated with existing AOFAS guidelines to further refine the essential components of a core foot and ankle curriculum.