Foot and ankle experience in orthopedic residency: an update

Variability in Surgical Case Volume Performed During ACGME-Accredited Orthopaedic Foot and Ankle Fellowship Training

INTRODUCTION

Previous studies have demonstrated a positive correlation between case volume and outcomes in foot and ankle surgery. This study elucidates surgical case volume benchmarks for Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic foot and ankle fellowship training in the United States.

METHODS

The ACGME provided case logs for orthopaedic residents and foot and ankle fellows (2018-2021). Variabilities in reported fellowship case volumes were defined as the fold-difference between 90th and 10th percentiles. Reported case volumes were compared between training cohorts with parametric tests.

RESULTS

Case logs from 65 orthopaedic foot and ankle fellows and 3146 orthopaedic residents were included. Fellows reported 1.3- to 1.5-fold more foot and ankle cases during fellowship training than during residency training (P < .001). On average, orthopaedic foot and ankle fellows reported 405.4 cases and most were arthrodesis (17%), forefoot reconstruction (17%), mid/hindfoot reconstruction (13%), tendon repair/transfer (12%), and trauma ankle hindfoot (11%). Case categories with the highest variabilities were amputation (14.8-fold difference), infection/tumor (11.6-fold difference), arthroscopy (9.2-fold difference), and calcaneus (8.7-fold difference).

DISCUSSION

Case volume benchmarks can assist trainees and faculty during orthopaedic foot and ankle training. More research is needed to determine case minimum requirements needed for autonomous practice in foot and ankle surgery.

LEVEL OF EVIDENCE

Level III.

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.

Trends in Leadership Within Orthopedic Foot and Ankle Fellowships

Background:

No study in the orthopedic literature has analyzed the demographic characteristics or surgical training of foot and ankle fellowship directors (FDs). Our group sought to illustrate demographic trends among foot and ankle fellowship leaders.

Methods:

The American Orthopaedic Foot & Ankle Society (AOFAS) Fellowship Directory for the 2021 to 2022 program year was queried in order to identify all foot and ankle fellowship leaders at programs currently offering positions in the United States and Canada. Data points gathered included age, sex, race/ethnicity, location of surgical training, time since training completion until FD appointment, length in FD role, and individual research H-index.

Results:

We identified 68 fellowship leaders, which consisted of 48 FDs and 19 co-FDs. Sixty-five individuals (95.6%) were male, and 3 (4.4%) were female. As regards race/ethnicity, 88.2% of the leadership was Caucasian (n = 60), 7.4% was Asian American (n = 5), 1.5% was Hispanic/Latino (n = 1), and 1.5% was African American (n = 1). The average age was 51.5 years, and the calculated mean Scopus H-index was 15.28. The mean duration from fellowship training to fellowship leader position was 11.23 years.

Conclusion:

Leaders within foot and ankle orthopedic surgery are characterized by research prowess and experience, but demographic diversity is lacking.

Level of Evidence:

Level III.

Orthopaedic In-Training Examination Resources and Residency Training for the Foot and Ankle Domain

BACKGROUND

Residency programs use the annual Orthopaedic In-Training Examination (OITE) prepared by the American Academy of Orthopaedic Surgeons (AAOS) to monitor resident progress and prepare them for the part 1 of the American Board of Orthopaedic Surgeons (ABOS) Certifying Examination. The purpose of this study was to determine resources residents currently use to prepare for the OITE and also to learn about their perception of training they receive in the foot and ankle subspecialty in their program and their interest in foot and ankle fellowship after residency.

METHODS

An anonymous survey was sent to both allopathic programs and osteopathic residents to learn what resources residents used to study for the OITE, preparatory question sets, on-call resources, their perception on training received in foot and ankle surgery, and their intent to pursue fellowship training.

RESULTS

A total of 130 residents participated in the survey. The majority of residents in allopathic and osteopathic residencies used Orthobullets (OB) to prepare for the OITE and use this resource while on-call. Most residents also used OB question sets to study along with the AAOS self-assessment examinations. In total, 43.2% of osteopathic residents felt they did not get enough exposure to foot and ankle subspecialty while in training, in contrast to 31.2% of allopathic residents. A total of 35% of all orthopaedic surgery residents felt they lacked enough exposure to foot and ankle orthopaedic surgery. Only 7 residents (6%, 6 allopathic, 1 osteopathic) intended to pursue a foot and ankle fellowship following graduation.

CONCLUSION

Online resources such as OB continue to be frequently used by residents for preparation for the OITE. Greater than one-third of orthopaedic residents feel they do not get enough exposure to foot and ankle orthopaedic surgery. Improvement in this area could be helped by continued endeavors from the American Orthopaedic Foot and Ankle Society such as the Visiting Professor Program and Resident Scholarship Program.

LEVELS OF EVIDENCE

Level V: Single Cross-Sectional Study.

Variability in Foot and Ankle Case Volume in Orthopaedic Residency Training

Surgical case volume during orthopaedic surgical residency is a concern among trainees and program directors alike. With an ongoing trend toward further subspecialization and the rapid development of new techniques and devices, the breadth of procedures that residents are exposed to continues to increase. Accreditation Council for Graduate Medical Education surgical case logs from 2009 to 2013 for graduating orthopaedic surgery residents were examined to assess the national averages of orthopaedic procedures logged by graduating orthopaedic surgery residents in the leg/ankle and foot/toes categories. This investigation revealed that there was an 8% increase in the total number of leg/ankle cases and 12% increase in foot/toes cases performed by graduating orthopaedic surgery residents, which has not significantly increased from 2009 to 2013. Across years examined in this study, significant variability existed between the 10th and 90th percentiles for total foot and ankle resident case exposure (P < .05), particularly within ankle arthroscopy, where there was a 15-fold difference in the number of arthroscopy cases performed by residents in the 90th percentile compared with the 10th percentile. The overall volume of foot and ankle cases performed by graduating orthopaedic surgery residents has increased despite not being statistically significantly from 2009 to 2013.

LEVELS OF EVIDENCE

Level III: Cohort study.

Influence of podiatry on orthopedic surgery at a level I trauma center

Level I trauma centers frequently see trauma at or below the ankle, which requires consultation with the orthopedic surgery department. However, as podiatry programs begin to firmly establish themselves in more Level I trauma centers, their consultations increase, ultimately taking those once seen by orthopedic surgery. A review of the literature demonstrates that this paradigm shift has yet to be discussed. The purpose of this study was to determine how many, if any, lower extremity fracture consultations a newly developed podiatry program would take from the orthopedic surgery department. A retrospective review was performed of emergency department records from January 2007 to December 2011. Seventeen different emergency department diagnoses were used to search the database. Ultimately, each patient's emergency department course was researched. Several trends were noted. First, if trauma surgery was involved, only the orthopedic surgery department was consulted for any injuries at or below the ankle. Second, the emergency department tended to consult the podiatry program only between the hours of 8 am and 6 pm. Third, as the podiatry program became more established, their number of consultations increased yearly, and, coincidentally, the orthopedic surgery department's consultations decreased. Finally, high-energy traumas involved only the orthopedic surgery department. Whether the orthopedic surgery department or podiatry program is consulted regarding trauma surgery is likely hospital dependent.