Findings will be used to pitch the appeal of foot and ankle to residents

The leaders of the American Orthopaedic Foot & Ankle Society (AOFAS) think they and their members are part of an exciting, satisfying, and multifaceted practice focus. They’d like to be sure the word gets out to aspiring orthopaedic surgeons.

With the objective of providing useful information about foot and ankle surgery to orthopaedic residents mulling their choices for subspecialization and fellowship program, AOFAS conducted a survey of its member fellows who are two to seven years in practice.

“We think foot and ankle surgery is a great subspecialty, with broad practice variety and widespread opportunity,” said James R. Holmes, MD, chair of the AOFAS Fellowship Committee, who oversaw the survey initiative. “We wanted to check with people who are establishing their practice to see if their experience confirmed what we believe.”

Misconceptions and challenges

Passionate orthopaedic practitioners of foot and ankle surgery may face several challenges in sharing their enthusiasm with rising surgeons. Among the concerns or misconceptions that residents may harbor is that they would be restricted to treating foot and ankle problems exclusively, with little exposure to more general orthopaedic conditions. They also may believe that they would face an excessive burden of providing diabetic foot care. On top of these challenges lies the reality that the patient population has a provider overlap with podiatrists.

Dr. Holmes said the survey of AOFAS fellows was undertaken to address these concerns, as well as the variable exposure to foot and ankle surgery residents may receive during training. The survey also sought to address the differences in the practice profiles to which residents are exposed and the common post-training practice experiences, as well as other potential but unknown factors. Noting that residents typically decide after their third year what direction they will go with fellowship applications, Dr. Holmes, the associate residency program director for orthopaedic surgery at the University of Michigan, observed, “That’s pretty early. Some programs have minimal foot and ankle exposure before that time in their training. We don’t want any residents making decisions with insufficient information.”

The survey sought specifically to characterize the practice profiles of recent graduates of orthopaedic foot and ankle fellowships, with the idea that the information obtained would be disseminated to help residents in training make career decisions and to help mentors provide accurate counsel to their mentees.

The survey, which was kept deliberately brief (60 to 90 seconds to complete) was sent electronically to 352 surgeons, of whom 154 responded. Results showed that 49 percent of respondents were in private practice, 25 percent were in academics, 19 percent were hospital employed, and 7 percent were in a multispecialty group. This profile mostly parallels that of AAOS members at large (Fig. 1).

Further review of their foot and ankle practice distribution revealed that a third of their volume involved trauma, 27 percent was reconstruction (e.g., flatfoot, cavus foot, fusions), 24 percent was sports (e.g., ankle scopes, Achilles tendon repairs), 11 percent was diabetic foot care, and 6 percent was other (Fig. 2).

Broadly breaking down diabetic foot care at their institutions, respondents estimated that 27 percent of cases were treated primarily by podiatry, 25 percent by orthopaedic surgery, 24 percent in a multidisciplinary wound care center, 15 percent by vascular surgery, 4 percent each by plastic and general surgery, and 1 percent by other.

Asked to rate the quality of desirable job opportunities immediately after fellowship, 45 percent said they had found many attractive opportunities, 32 percent said opportunities were satisfactory, 21 percent reported limited options due to specific practice type or geography, and only 2 percent said options were limited.

Rating their current job opportunities, 28 percent said there were many attractive opportunities, 25 percent said they were satisfactory, 15 cited personal limits in practice type or geography as influencing perceived options, and only 1 percent reported limited options, while 31 percent said they were not looking or had no opinion.

Good jobs plentiful

Dr. Holmes said the overall results suggest that foot and ankle fellows in the early stages of practice perceive that attractive jobs in the field are plentiful and found in multiple settings. Most, he noted, perform foot and ankle surgery exclusively. Seventy-eight percent take orthopaedic trauma call, and the accompanying surgical case volume accounts for most of the remainder of their cases. The respondents treat a large variety of foot and ankle cases, with trauma, reconstruction, and sports well represented. They devote just 11 percent of their time to diabetic foot care, with only about 25 percent of such care handled by an orthopaedics service at their institution.

“These results show that within foot and ankle surgery, individuals can tailor their practice to their interests,” Dr. Holmes said. “People who like to do more sports can do that. Or reconstruction. Or primarily trauma. There is a great deal of latitude within the specialty, both operative and nonoperative.

“We have extensive, fundamental training that starts in medical school and continues with general surgery training early on, combined with solid biomechanical, anatomical, and surgical principles throughout a five-year residency with continuous foot and ankle study,” he said. “This broad-based and extensive training, often combined with an additional subspecialty year of focus, means we are best positioned to be the premier providers of operative and nonoperative foot and ankle care.”

Trends favorable?

Dr. Holmes said that several factors and trends portend a bright future for foot and ankle surgery. Historically, he said, need for foot and ankle surgery greatly increased during the “polio era,” when tendon transfers and fusion procedures were developed and refined for the treatment of those patients. After polio was eradicated, orthopaedic focus turned to new technology and developments in arthroplasty, trauma, and sports medicine. “The foot became somewhat neglected as other things took off,” he said.

Now, he said, “foot and ankle surgery is seeing a period of dynamic growth in both what we understand—such as the biology of tendon repair and molecular signaling—and in technology. Total ankle replacement is becoming more prevalent. Computer-assisted design and manufacturing continue to rapidly evolve. There is greater understanding and utilization of nonoperative treatments, such as rehabilitation protocols for Achilles tendon tears, with the biology and physiology better understood.”

Dr. Holmes said that the survey results, which arrive as AOFAS is carrying out a rebranding campaign to elevate the profile of foot and ankle surgery within the profession and to the public, should help in the effort to promote the subspecialty to orthopaedic residents as they apply to fellowship programs. Currently, there are 78 fellowship slots within 50 programs, providing ample opportunity for excellent advanced training.

To foster familiarity and understanding, AOFAS also conducts several programs, including a visiting professor program. In addition, the Resident Scholar Program, which is designed to expose midlevel residents to the orthopaedic foot and ankle subspecialty at the AOFAS annual meeting, has been an overwhelming success.

Overall, Dr. Holmes is optimistic. “We are seeing a resurgence in interest in foot and ankle surgery. It’s our turn. We have a lot of bright, engaged orthopaedists in academic centers whose focus is foot and ankle surgery, and an ever-enlarging group of expert orthopaedic clinicians taking great care of people.”

AOFAS and practicing orthopaedic surgeons understand there are other providers of foot and ankle care, he noted. “The relationship between podiatry and orthopaedics is fluid and evolving. Both are finding ways in which they can coexist, cooperate, and ultimately provide the best care for our patients.”

Terry Stanton is the senior science writer for AAOS Now. He can be reached at tstanton@aaos.org.