Foot and Ankle Questions on the Orthopaedic In-Training Examination: Analysis of Content, Reference, and Performance

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1 Foot and Ankle Questions on the Orthopaedic In-Training Examination: Analysis of Content, Reference, and Performance Cameron R. Barr, MD; Ivan Cheng, MD; Loretta B. Chou, MD; Kenneth J. Hunt, MD abstract Full article available online at Healio.com/Orthopedics. Search: 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 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. Figure: National resident performance scores for the committee-defined foot and ankle questions. Scores are reflected as an average for level of training and presented as a percentage of questions answered correctly. Abbreviations: OITE, Orthopaedic In-Training Examination; PGY, postgraduate year; YIT, year-in-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. Drs Barr, Cheng, Chou, and Hunt are from the Department of Orthopaedic Surgery, Stanford University, Redwood City, California. Drs Barr, Cheng, Chou, and Hunt have no relevant financial relationships to disclose. Correspondence should be addressed to: Loretta B. Chou, MD, Department of Orthopaedic Surgery, Stanford University, 450 Broadway St, MC 6342, Redwood City, CA (lchou@stanford.edu). doi: / e880

2 Foot and Ankle Questions on the OITE Barr et al The Orthopaedic In-Training Examination (OITE) has been implemented since 1963 to monitor the training and knowledge of orthopedic surgery residents. 1,2 Created by the American Academy of Orthopaedic Surgeons (AAOS), it was the first subspecialty training examination used to determine national standards for trainees and evaluate the quality of educational programs. Administered annually, the examination consists of approximately 275 questions and covers 12 domains of orthopedic surgery, including foot and ankle, hand, hip and knee reconstruction, musculoskeletal trauma, medically related issues, orthopedic diseases, basic science and tumors, pediatric orthopedics, rehabilitation, shoulder and elbow, spine, and sports medicine. Most residency training programs have focused on improving resident education through the evaluation of OITE performance. Several sections of the examination have been analyzed in the recent literature. Studies have evaluated the pathology, sports medicine, trauma, hand, hip and knee reconstruction, and foot and ankle sections Srinivasan et al 9 previously analyzed 5 years of OITE questions classified as foot and ankle. They identified the most common topics, treatments, and imaging modalities tested, as well as the taxonomy classification of the questions. However, given the amount of overlap between foot and ankle topics and other subspecialties (ie, musculoskeletal trauma, pediatric orthopedics, and sports medicine), a more inclusive review of questions and topics tested may provide a more comprehensive approach to the foot and ankle teaching curriculum. Furthermore, posttest data allow for a detailed analysis of resident performance by year, providing an additional benefit for monitoring resident performance and creating an organized, structured educational model in this diverse subspecialty area. The current authors evaluated OITE test questions over a 5-year period to provide a thorough analysis of the test questions relating to foot and ankle topics. Data assessed included question topic, treatment tested, taxonomy, imaging modality tested, references cited, and national resident performance by year in training. The authors ultimate goal is to optimize an efficient and streamlined curriculum for foot and ankle education among orthopedic residency programs and foot and ankle fellowships. Materials and Methods The authors evaluated the OITE over a 5-year period (2006 through 2010). After accounting for questions removed by the examination committee prior to test scoring, the authors recorded the total number of questions for each testing year. Each question was then manually evaluated for content pertaining to foot and ankle surgery. The total number of questions relating to the foot and ankle was recorded for each of the 5 years examinations. This included, but was not limited to, the questions delineated as foot and ankle by the AAOS examination committee. Questions categorized as musculoskeletal trauma, pediatric orthopedics, sports medicine, rehabilitation, basic science and tumors, orthopedic diseases, and medically related issues were also included if the primary question topic pertained to the foot and ankle. The authors then calculated the weight of the foot and ankle questions (those categorized as foot and ankle and in total) as a fraction of the entire OITE. An analysis was performed of all identified questions for content, cited references, and resident performance. Content Question content was recorded for each of the foot and ankle questions. This included topic tested, imaging modality, treatment method, and taxonomic classification. For ease of reference and proposed teaching topics, questions were classified under general categories or topic areas: deformity, trauma, rehabilitation, heel pain, diabetic foot, sports, neurologic, greater toe, lesser toe, pediatric, tumor, arthritis, and tendon disorder. Questions that involved a figure with imaging were recorded as containing a radiograph, magnetic resonance imaging (MRI), computed tomography (CT) scan, clinical photograph, and/or clinical video. Treatment methods, when tested, were categorized by procedure type. Finally, using a previously cited classification system, 11 questions were assigned to a taxonomic number: taxonomy 1 (knowledge) requires the recall of orthopedic practice or literature, taxonomy 2 (comprehension) requires the interpretation of information and/or a diagnosis, and taxonomy 3 (application) requires the formulation of a treatment plan from provided information. Cited References For each identified question, the recommended references provided by the AAOS evaluation committee were reviewed. Journal and textbook titles were recorded. Book editors, but not article authors, were included for title recognition. Multiple references were frequently listed for 1 question. Resident Performance Using posttest data provided from the AAOS evaluation committee, the overall number of orthopedic surgery residents sitting for the OITE was recorded for each year in the study period. This was further divided into year in training, including year-in-training (YIT)-1 (postgraduate year [PGY] 2), YIT-2 (PGY3), YIT-3 (PGY4), and YIT-4/5 (PGY 5/6). Overall resident performance was recorded and analyzed by year-in-training. Because the AAOS only provides resident performance data by domain tested, this analysis was only performed for the questions categorized as foot and ankle by the evaluation committee. Results Over the 5-year period of this investigation, a total of 1341 questions were JUNE 2012 Volume 35 Number 6 e881

3 Table 1 Breakdown of Foot and Ankle OITE Questions by Specialty Domain Year Total OITE Total Foot and Ankle (%) Foot and Ankle Trauma Pediatric Rehabilitation Sports Orthopedic Diseases Basic Science and Tumors (15.5) (12.0) (15.2) (12.6) (14.1) scored on the OITE examinations, with an average of questions per year (range, questions). The number of questions classified as foot and ankle by the testing committee totaled 87, with an average of 17.4 questions per year (range, questions). This accounts for 6.5% (87/1341) of the total questions. However, by including all foot and ankle topics tested in other domains, the total number of questions pertaining to foot and ankle surgery increased to 186, with an average of 37.2 questions per year (range, questions). Several foot and ankle questions appeared in the musculoskeletal trauma, pediatric orthopedics, rehabilitation, and sports domains. When including all domains, the weight of foot and ankle questions increased to 13.9% (186/1341) of the OITE (Table 1). Content Table 2 lists the foot and ankle topics tested from 2006 to Each question was categorized into 13 proposed general teaching topics. Of the 186 total questions identified, the vast majority (approximately 75% [139/186]) can be categorized into the following 6 topic areas: foot and ankle trauma (54 questions, 29%), the pediatric foot (24 questions, 12.9%), foot and ankle deformity (19 questions, 10.2%), the diabetic foot (15 questions, 8.1%), rehabilitation (14 questions, 7.5%), and the great toe (13 questions, 7.0%). Subcategory analysis identified that the top 5 individual topics most tested were ankle fracture (22 questions), flatfoot (14 questions), calcaneus fracture (12 questions), clubfoot (8 questions), and diabetic ulcer (8 questions). Imaging modalities, including radiographs alone, photographs, a combination of radiographs and photographs, MRI, CT scan, and video attachments, were tested in approximately half of the foot and ankle OITE questions (90/186, 48.4%) (Table 3). Treatment methods on the OITE were tested for an average of 58.1% (108/186) of the foot and ankle questions per year (range, 55.9%-62.2%) over the 5-year study period. Table 4 lists the treatment methods that were tested at least twice over 5-year study period, including open reduction and internal fixation and nonoperative treatment (cast/brace, orthotics/ prosthetics, physical therapy/exercises, observation, antibiotics). The most common taxonomic classification of foot and ankle questions on the analyzed examinations was knowledge and recall (taxonomy 1), which accounted for 49% (91/186) of all identified questions. Evaluation and decision making (taxonomy 3) accounted for 37% (69/186) of the questions, whereas diagnosis and interpretation (taxonomy 2) accounted for 14% (26/186) of the questions (Table 5). Cited References Over the 5-year study period, 420 total references in 61 sources (28 textbooks and 33 journals) were cited for the foot and ankle questions. An average of 84 references (range, references) were listed per year with each question having approximately 2 references. Of the total citations, 67.9% (285/420) came from journals and 32.1% (135/420) came from textbooks. Tables 6A and 6B list all sources that were cited >2 times. More than half of all the cited references (234/420, 55.7%) were limited to 5 sources. This includes 2 journals, 1 textbook, 1 review journal, and 1 review book. Resident Performance Over the 5-year study period, 18,398 residents took the OITE, with an average of 3680 residents (range, residents) per year sitting for the examination. The Figure shows the average scores for the committee-designated foot and ankle questions by level of training. Based on the average number of foot and ankle questions per year (17.4), mean resident performance improved with each successive year in training: YIT-1, 54.1% (9.42/17.4); YIT-2, 61.5% (10.7/17.4); YIT-3, 66.2% (11.52/17.4); YIT-4/5, 69.3% (12.06/17.4). Although a comprehensive statistical analysis cannot be performed because no standard deviations were provided in the score reports, the largest increase in foot and e882

4 Foot and Ankle Questions on the OITE Barr et al Table 2 Foot and Ankle Topics Tested on the OITE Topic Total Trauma Ankle fracture Calcaneus fracture Lisfranc injury Subtalar dislocation Syndesmosis injury Talus fracture Pilon fracture Ankle dislocation 1 1 Metatarsal fracture 1 1 Pediatric foot Clubfoot Verticle talus Tarsal coalition Intoeing Outtoeing Congenital curly toes Kohler s disease 1 1 Assesory navicular 1 1 Osteomyelitis 1 1 Deformity Flatfoot Midfoot anatomy Hindfoot varus Cavus Calcaneal deformity 1 1 Ankle contracture 1 1 Diabetic foot Ulcer Charcot foot Amputation Rehabilitation Amputation Gait Orthotics Prosthetics Great toe Hallux rigidus Hallux valgus ankle scores occurred between YIT-1 and YIT-2, after which scores began to plateau. Combined resident performance on the foot and ankle sections (average, 62.2%; range, 51.8%-67.1%) was similar to that on the entire examination (average, 60.0%; range, 57.0%-61.9%). Discussion The OITE is an annually administered examination used nationally to evaluate orthopedic surgery resident education. Performance on the test has been shown to be predictive of passing scores on the American Board of Orthopaedic Surgery Part I written examination. 40,41 The purpose of the current study was to analyze 5 years of OITE questions pertaining to foot and ankle surgery. The authors ultimate goal in this comprehensive analysis is to allow for the creation of an optimal foot and ankle teaching curriculum that includes the source material from which the questions are drawn. In 2009, Srinivasan et al 9 reported on the question content in the foot and ankle section of the OITE. The current authors results indicate that when broadly evaluating foot and ankle topic areas on more recent examinations, trauma-focused questions continue to be the most commonly tested (29% of foot and ankle questions [54/186]). Inclusion of other subspecialty domains in the current study emphasizes that the breadth of foot and ankle topics covered is noticeably larger. Compared with the 34 topics listed by Srinivasan et al, 9 the current authors identified 62 foot and ankle related topics covered. Pediatric questions accounted for approximately 15% (24/186) of the questions. When medically related and rehabilitation questions were included, almost 10% (15/186) of the questions pertained to the diabetic foot. As a foot and ankle teaching curriculum is developed and as residents prepare for foot and ankle questions on the OITE and the American Board of Orthopaedic Surgery Part I examination, the focus should include topics inside and outside of the defined foot and ankle domain. The JUNE 2012 Volume 35 Number 6 e883

5 most commonly tested topics on recent examinations include foot and ankle trauma (ankle and calcaneus fractures), the pediatric foot (clubfoot), foot and ankle deformity (flatfoot), the diabetic foot (ulcer care), and the great toe (hallux valgus and rigidus). Treatment of these conditions should also be stressed because open reduction and internal fixation and nonoperative management remained the most commonly tested treatment modalities. The current authors found that knowledge of imaging modalities is also frequently tested on the OITE. Of the evaluated questions in this study, 48.4% (90/186) required knowledge of imaging modalities. This is in comparison with analyses of the sports and trauma sections of the OITE, 3,8 where 27.4% (29/106) and 30.2% (77/255), respectively, of the questions required evaluation of imaging modalities. The most common imaging modality is plain radiographs of the foot and ankle; testing on other imaging modalities is rare for foot and ankle questions. Questions including images will likely remain frequent because computer testing now allows for high-quality images and videos. Although the authors results show that foot and ankle OITE questions have been created from.60 sources, the majority of the questions are referenced to a few journals and textbooks. Residents should focus primarily on articles in Foot and Ankle International, The Journal of Bone and Joint Surgery American Volume, and Journal of the American Academy of Orthopaedic Surgeons. In addition, residents should use Surgery of the Foot and Ankle 23 as a reference book. Analysis of national resident performance data on the foot and ankle section of the OITE shows that although a trend exists toward improved scores with each higher level of training, the majority of knowledge is gained between YIT-1 and YIT-2. This is similar to the results found by Cross et al, 3 who evaluated the performance on the musculoskeletal trauma section of the OITE. Table 2 Continued Foot and Ankle Topics Tested on the OITE Topic Total Tendon disorder Achilles tendon injury FHL injury Peroneal subluxation 1 1 Peroneal tendon anatomy 1 1 Peroneal tendon injury 1 1 Sports Ankle sprain/instability Jones fracture 2 2 OCD Anterior impingement Navicular fracture 1 1 Ankle arthroscopy 1 1 Heel pain Plantar fasciitis Lateral plantar nerve Lesser toe Claw toe Hammer toe 1 1 Metatarsalgia 1 1 Plantar plate injury 1 1 MTP dislocation 1 1 Bunionette 1 1 Arthritis Ankle arthrodesis 2 2 Subtalar arthrodesis Gout 1 1 Total ankle replacement 1 1 Tibiotalocalcaneal arthrodesis Neurologic 1 1 Charcot Marie Tooth Tumor Synovial sarcoma 1 1 Soft tissue mass 1 1 PVNS 1 1 Exostoses 1 1 Abbreviations: FHL, flexor hallucis longus; OCD, osteochondral defect; OITE, Orthopaedic In-Training Examination; PVNS, pigmented villonodular synovitis. e884

6 Foot and Ankle Questions on the OITE Barr et al Table 3 Imaging Modalities Tested on the OITE Type of Imaging Total None Radiograph Photograph MRI CT Radiograph and photograph Radiograph and MRI Radiograph and CT Radiograph and video MRI and CT Abbreviations: CT, computed tomography; MRI, magnetic resonance imaging; OITE, Orthopaedic In-Training Examination. Table 4 Treatment Methods Tested on the OITE a Treatment Total None Open reduction internal fixation Arthrodesis Cast/brace Orthotics/prosthetics Combination (soft tissue and bone) Amputation Tendon transfer Osteotomy Debridement Observation Tendon repair or lengthening Arthroscopy Physical therapy/exercises a Treatments tested once during the study period: external fixation, total ankle replacement, chielectomy, epiphyseodesis, resection arthroplasty, and antibiotics. Several recommendations can be made from the current study to create or improve a residency program s foot and ankle curriculum. First, a structured lecture or reading schedule should be created to cover the topics commonly tested on the OITE. This can be broken down into general topics (Table 2). Second, residents and instructors should be directed to high-yield reading material and should avoid getting bogged down in the abundance of options. Focus on a few journals (Foot and Ankle Interna- JUNE 2012 Volume 35 Number 6 e885

7 Table 5 Taxonomic Classification of Foot and Ankle Questions on the OITE % (n/n) Classification Knowledge and recall 45.2 (19/42) 53.1 (17/32) 56.1 (23/41) 50 (17/34) 40.5 (15/37) Diagnosis and interpretation 19 (8/42) 9.4 (3/32) 12.2 (5/41) 17.6 (6/34) 10.8 (4/37) Evaluation and decision making 35.8 (15/42) 37.5 (12/32) 31.7 (13/41) 32.4 (11/34) 48.6 (18/37) Table 6A Journals Cited as References for OITE Answers a No. of Times Cited Journal Total Foot and Ankle International b The Journal of Bone and Joint Surgery American Volume Journal of the American Academy of Orthopaedic Surgeons Clinical Orthopaedics and Related Research Journal of Orthopaedic Trauma Journal of Pediatric Orthopedics Foot and Ankle Clinics The Journal of Bone and Joint Surgery British Volume American Journal of Sports Medicine Orthopedics Clinical Orthopaedics 4 4 Injury: International Journal of the Care of the Injured The Journal of Trauma Archives of Physical Medicine and Rehabilitation a Nineteen journals were cited 1 time during the study period: Prosthetics and Orthotics International, The Orthopedic Clinics of North America, Biomechanics, The Journal of Foot Surgery, American Journal of Orthopedics, Journal of Clinical Oncology, Archives of Orthopaedic and Trauma Surgery, Archives of Surgery, Arthroscopy: The Journal of Arthroscopic and Related Surgery, Physical Therapy, Clinical Biomechanics, Diabetes Care, The Pediatric Infectious Disease Journal, The Journal of Foot and Ankle Surgery, Lancet, Radiologic Clinics of North America, The New England Journal of Medicine, The Journal of American Medical Association, Pediatrics. b This includes articles from Foot and Ankle prior to the journal s change to its current name. tional, The Journal of Bone and Joint Surgery American Volume, and Journal of the American Academy of Orthopaedic Surgeons) and 1 textbook (Surgery of the Foot and Ankle 23 will prepare the resident for the majority of questions. Third, residents should continually be guided by teaching physicians to improve their knowledge throughout their years in training. In addition to junior-level residents, senior residents should also be asked questions in conferences, clinics, or operating rooms to prevent a plateau in knowledge. The importance of consistent and persistent didactic teaching, individualized review of the literature, and an efficient topic-focused curriculum is underscored by the diversity of foot and ankle education in United States residency training programs. More than one-third of programs have no clinical rotation dedicated to foot and ankle, and more than half (54%) only have 1 faculty member dedicated to foot and ankle orthopedics. 42 It has been shown that performance on the foot and ankle questions improves by 12% after the completion of a formal foot and ankle rotation. 43 Because residents do not get as much clinical exposure to the foot and ankle during training as many of the e886

8 Foot and Ankle Questions on the OITE Barr et al Table 6B Textbooks Cited as References for OITE Answers a No. of Times Cited Textbook Total Surgery of the Foot and Ankle Orthopaedic Knowledge Update: Foot and Ankle Orthopaedic Knowledge Update: Home Study Syllabus Rockwood and Green s Fractures in Adults AAOS Instructional Course Lectures Foot and Ankle Orthopaedic Knowledge Update: Sports Medicine Lovell and Winter s Pediatric Orthopaedics Orthopaedic Knowledge Update: Pediatrics Skeletal Trauma Tachdjian s Pediatric Orthopaedics Disorders of the Foot and Ankle: Medical and Surgical Management Anatomy for Surgeons Sarrafian s Anatomy of the Foot and Ankle: Descriptive, Topographic, Functional Atlas of Limb Prothetics: Surgical, Prosthetic, and Rehabilitation Principles Functional Reconstruction of the Foot and Ankle Congenital Clubfoot: Fundamentals of Treatment Levin and O Neal s The Diabetic Foot a Eleven textbooks were cited 1 time during the study period: Foot and Ankle Disorders, 12 Orthopaedic Knowledge Update: Musculoskeletal Tumors, 13 Orthopedics Sports Medicine, 14 Medicare Carriers Manual, 15 Surgical Treatment of Orthopaedic Trauma, 16 Review of Sports Medicine and Arthroscopy, 17 Chapman s Orthopaedic Surgery, 18 Diabetes Mellitus: Theory and Practice, 19 Master Techniques in Orthopaedic Surgery: Fractures, 20 Advanced Reconstruction of the Foot and Ankle, 21 Practice of Pediatric Orthopaedics. 22 other commonly tested subspecialties, a thorough, efficient, and proficient curriculum is vital to optimize education and examination performance. Some inherent limitations exist to this study. The analysis includes a 5-year period of OITE questions. Although inclusion of more years would allow for a more comprehensive analysis, this time period is consistent with other similar studies and represents a resident s length of training. Furthermore, some bias may exist in inclusion and categorization of the data, specifically in addressing those questions not identified as foot and ankle by the testing committee. Taxonomic classification is not available in the OITE reports. However, Buckwalter et al 11 showed an 85% agreement between test makers and residents when evaluating questions. Figure: National resident performance scores for the committee-defined foot and ankle questions. Scores are reflected as an average for level of training and presented as a percentage of questions answered correctly. Abbreviations: OITE, Orthopaedic In-Training Examination; PGY, postgraduate year; YIT, year in training. JUNE 2012 Volume 35 Number 6 e887

9 Conclusion This analysis provides residents and instructors with valuable data to improve orthopedic foot and ankle education curricula. With the development of an improved foot and ankle focused teaching curriculum based on these data, test performance and clinical practice can improve. References 1. Mankin HJ. The Orthopaedic In-Training Examination (OITE). Clin Orthop Relat Res. 1971; 75: Mankin HJ, Carter RM, Krawczyk M. The effect of permissive environment on scoring of the orthopaedic in-training examination. J Bone Joint Surg Am. 1973; 55(5): Cross MB, Osbahr DC, Gardner MJ, et al. An analysis of the musculoskeletal trauma section of the Orthopaedic In-Training Examination (OITE). J Bone Joint Surg Am. 2011; 93(9): Cross MB, Osbahr DC, Nam D, et al. An analysis of the hip and knee reconstruction section of the Orthopaedic In-Training Examination. Orthopedics. 2011; 34(9):e550-e Frassica FJ, Papp D, McCarthy E, Weber K. 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