Orthopaedic Surgery Residency Program

Michael Herbenick, M.D., Director

Specific Objectives for the Foot and Ankle Rotation Service

By the end of the foot and ankle rotation, the junior resident will know and be able to:

1. Workup and present a patient with a foot/ankle problem specifying the working diagnosis, additional studies to confirm or change the diagnosis, the treatment alternatives and expected outcome. This includes demonstrating the ability to take a detailed history and perform an accurate foot and ankle exam.
2. Recognize and take into account the lower extremity angular and rotational
alignment, foot type, footwear, relevant biomechanics, and lifestyle.
3. Prescribe an appropriate orthotics/prosthetics and shoe wear modifications.
4. Describe the natural history of the patient's problem if untreated, treated non-operatively and treated operatively.
5. Correctly assist and apply dressings, splints, and casts for protecting injuries and postoperative conditions.
6. Perform local anesthesia to include: ankle, metatarsal and digital blocks; field local infiltration; joint injection for pain localization.
7. Demonstrate pre-op readiness by specifying the following for each case:

  • Surgical indications and goals
  • Incision, approach relevant anatomy and step-by-step procedure
  • Three-dimensional considerations
  • Expected difficulties and potential pitfalls
  • Contingency plans
  • Criteria of acceptable result

8. Perform and assist surgical procedures for common foot and ankle problems:
hammertoe, bunions, tendon xfers, ankle subtalar and single joint fusions,
excision of OCD's, osteotomies, ankle ligament reconstruction, removal of
hardware.
9. List the equipment needed for all the basic procedures and demonstrate the ability
to correctly review the completeness of this equipment before starting a procedure.
10. Demonstrate attention to detail in followup for postoperative patients.
11. Recognize the postop foot/ankle in trouble.
12. Demonstrate the ability to recognize and initiate treatment of complications.
13. Critique foot and ankle literature at the department and foot/ankle journal clubs.

Reading and Reference List:

International Journal of Foot and Ankle Surgery
Surgery of the Foot and Ankle - Mann/Coughlin
OKU - Foot and Ankle
Functional Reconstruction/Foot and Ankle - Hansen
Disorder of the Foot and Ankle - Jahss
Foot and Ankle Disorders - Myerson
Modified from Fred Lippert - Orthopaedic Educator's Course

Knowledge Map:

Knowledge maps are created in an attempt to "map" the learner's knowledge base. Pre-existing objectives are used to identify the content area, which the learner plans to master. These objectives are easily converted into a "knowledge map" by placing three circles beside each individual objective. The number of circles that are filled in beside each objective represents the learner's perception of his/her knowledge and understanding of that particular objective.

Three Blank Circles - (ooo) means the learner believes he/she has no knowledge of that topic.
One Circle filled - (ooo) means that the learner feels he/she has some rudimentary understanding of the subject.
Two out of Three circles filled - (ooo) means a significant, but still incomplete understanding of the subject.
All three circles filled - (ooo) means the learner feels he/she has mastered that specific objective to the satisfaction of the course's requirements, or in the case of a residency rotation, to the point where he/she can practice competently in that area on their own.

The premise behind the knowledge map is that the learner is the best judge of the extent of knowledge and depth of understanding they have of each subject area. By making explicit their perception of their knowledge of a particular subject area, the learner can benefit in a number of ways.

First, reflection on what has been learned, and what needs to be learned will help to clarify study efforts.
Second, a knowledge map will allow the learner and teacher to identify knowledge deficits which must be addressed.
Third, discrepancies between the learner's perception of what he/she knows and what is actually known as determined by the teacher can be more easily identified and subsequently rectified.
Finally, knowledge maps, because they are intimately linked to the course/rotation objectives, offer all the potential advantages of objectives; namely, they help to clarify the important content that is mastered and can serve as a fair template for evaluation.

It is important to state that for objectives (and their associated knowledge maps) to be used effectively, certain principles must guide their use. First, the objective document must reflect relevant content. Second, the objective's content and use must be the product of negotiation between the learner and teacher prior to the start of the rotation. Third, objectives must be closely tied to the system of evaluating him/her on a completely different area is not only unfair, but grossly undermines the potential effectiveness of the objectives as a learning tool. Finally, objectives must be dynamic and constantly evolving just as our understanding of the subject matter evolves.

Stephen Pinney, M.D., M.Ed., FRCS


Foot and Ankle Rotation - Specific Objectives

Interpersonal and Communications Skills:

Residents will, at all times, demonstrate behavior that is beyond reproach. Residents must be able to demonstrate interpersonal and communications skills that result in effective information exchange and teaming with patients, patient's families, and professional associates. Residents are expected to:

  • Demonstrate honest, open, civil, and effective communication with patients, staff, and colleagues (medical students, residents & attendings).
  • Create and sustain a therapeutic and ethically sound relationship with patients
  • Use effective listening skills Elicit and provide information using effective nonverbal, explanatory, questioning, and writing skills
  • Work effectively with others as a member or leader of a health care team or other professional group

Practice-Based Learning and Improvement:

Residents must be able to investigate and evaluate their patient care practices, appraise and assimilate scientific evidence, and improve their patient care practices. Residents are expected to:

  • Analyze practice experience and perform practice-based improvement activities using a systematic methodology.
  • Locate, appraise, and assimilate evidence from scientific studies related to their patients' health problems.
  • Apply knowledge of study designs and statistical methods to the appraisal of clinical studies and other information on diagnostic and therapeutic effectiveness.
  • Use information technology to manage information, access on-line medical information, and support their own education.
  • Facilitate the learning of students and other healthcare professionals.

Professionalism:

Residents must demonstrate a commitment to carrying out professional responsibilities, adherence to ethical principles, and sensitivity to a diverse patient population. Residents are expected to:

  • Demonstrate respect, compassion, and integrity
  • A responsiveness to the needs of patients and society that supercedes self-interest
  • Accountability to patients, society, and the profession
  • Commitment to excellence and on-going professional development
  • Demonstrate a commitment to ethical principles pertaining to:
    • Provision or withholding of clinical care,
    • Confidentiality of patient information
    • Informed consent
    • Business practices
  • Demonstrate sensitivity and responsiveness to patients' culture, age, gender, and disabilities

Systems-Based Practice:

Residents must demonstrate an awareness of and responsiveness to the larger context and system of healthcare and the ability to effectively call on system resources to provide care that is of optimal value. Residents are expected to:

  • Understand how their patient care and other professional practices affect other health care professionals, the health care organization, and the larger society and how these elements of the system affect their own practice
  • Know how types of medical practice and delivery systems differ from one another, including methods of controlling health care costs and allocating resources
  • Practice cost-effective health care and resource allocation that does not compromise quality of care
  • Advocate for quality patient care and assist patients in dealing with system complexities
  • Know how to partner with health care managers and health care providers to assess, coordinate, and improve health care and know how these activities can affect system performance

Medical Knowledge:

Residents must demonstrate knowledge about established and evolving biomedical, clinical, and cognate (e.g. epidemiological) sciences and the application of this knowledge to patient care. Residents are expected to:

  • Demonstrate an investigatory and analytic thinking approach to clinical situations
  • Know and apply the basic and clinically supportive sciences which are appropriate to foot and ankle surgery

Patient Care:

Residents must be able to provide care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to:

  • Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families
  • Gather essential and accurate information about the patient
  • Make informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment.
  • Develop and carry out patient management plans, counsel and educate patients and their families.
  • Use information technology to support patient care decisions and patient education.
  • Perform competently all invasive procedures considered essential in foot and ankle practice.
  • Provide health care services aimed at preventing health problems or maintaining health work with health care professionals, including those from other disciplines, to provide patient-focused care.
General Schedule:

Monday:
7:00 a.m. Conferences
8:00 a.m. Foot & Ankle Clinic (Med Surg Clinic)
11:00 a.m. Review Cases for week
History & Physicals should be done
X-rays reviewed as needed
12:00 p.m. Patient Office

Tuesday:
7:00 a.m. Conferences
9:15 a.m. O.R.

Wednesday:
7:00 a.m. Conference (Grand Rounds)
8:15 a.m. O.R.

Thursday:
7:00a.m. Conference
8:00 a.m. Patient Office

Friday:
Children's Conference
Educational Activity
Add-on Cases

General Patient Assessment Skills:

In a patient presenting with a complaint related to the foot or the ankle, the resident will demonstrate competency in the following skills:

OOO Obtaining a focused Patient History
OOO Performing an appropriate Physical Examination
OOO Demonstrate an understanding of basic gait assessment

Order and appropriately interpret relevant x-rays that may include:

OOO AP ankle
OOO Ankle Mortise
OOO Lateral Ankle
OOO AP Foot
OOO Lateral Foot
OOO Oblique Foot
OOO Axial Heel

Know the indications and basic interpretation of the following imaging studies:

OOO CT Scan
OOO MRI
OOO Bone Scan
Assessment and Treatment of Specific Conditions:

For the specific foot and ankle conditions listed below the resident will:

  • Make an accurate diagnosis
  • Competently perform any relevant condition-specific physical examination
  • Identify appropriate radiographic imaging studies
  • Outline the natural history of the specific condition
  • Outline the etiology, or possible etiologies of the specific condition
  • Describe appropriate non-operative treatment options (if they exist)
  • Describe appropriate operative treatment options (if they exist)
  • Describe possible complications of non-operative and operative treatment
  • Outline the prognosis of non-operative and operative treatment
Specific Foot and Ankle Conditions Specific Foot and Ankle Conditions
(Chronic): (Acute):
OOO Ankle Osteoarthritis OOO Achilles Tendon Rupture
OOO Osteochondral Lesion of Talus OOO Ankle Fracture
OOO Chronic Ankle Instability OOO Ankle Sprain
OOO Achilles Tendonitis OOO Talar Body Fracture
OOO Retrocalcane al Bursitis/ OOO Talar Neck Fracture
Haglund deformity OOO Calcaneal Fracture
OOO Subtalar Arthritis OOO Navicular Stress Fracture
OOO Tarsal Coalition OOO Nutcracker Fracture
OOO Peroneal Tendonitis OOO LisFranc Fracture /Dislocation
OOO Drop Foot OOO Base of 5th MT Fracture
OOO Plantar Fasciitis OOO Metatarsal Fracture
OOO Symptomatic Adult Flatfoot OOO Phalangeal Fractures
(Posterior Tibial Tendonitis) OOO Subungal Hematoma
OOO Cavovarus Foot
OOO Tarsometatarsal Arthritis
OOO Hallux Valgus
OOO Hallux Rigidus
OOO Metatarsalgia
OOO Morton's Neuroma
OOO Claw /Hammer toes
OOO Bunionette
OOO Ingrown Toenail
OOO Diabetic Foot Ulcer

Principles of Assessing and Treating General Foot and Ankle Problems:

For the general or systematic problems listed below, the resident will:

  • Demonstrate an understanding of the pathophysiology
  • Identify how this condition may affect the management of specific foot problems
  • Demonstrate an understanding of appropriate treatment principles
  • Recommend appropriate patient referral when indicated

General Foot and Ankle Problems:

OOO Diabetes
OOO Charcot-Marie-Tooth
OOO Cerebral Palsy
OOO Rheumatoid Arthritis/Inflammatory Arthritis
OOO Spinal Cord Injuries
OOO Peripheral Neuropathies
OOO Fungal Infections
OOO Chronic Pain Syndrome
OOO Reflex Sympathetic Dystrophy
OOO Osteoporosis
OOO Cigarette Smoking
OOO Worker's Compensation Issues

SURGICAL SKILLS:
For the basic surgical skills listed below the resident will:

  • Demonstrate competence in performing the described task.
  • Appreciate the pitfalls and possible complications
OOO Surgical Planning
OOO Prepping and Draping
OOO Use of a Tourniquet
OOO Choice of suture material
OOO Suture tying
OOO Regional Anesthetic Blocks
OOO Local Anesthetic Blocks
OOO Application of Short Leg Splint/Cast
OOO Application of an Unna Boot

For the specific surgical procedures listed below the resident will:

  • Identify the appropriate surgical approach
  • Describe potential pitfalls
  • Outline the operative procedure
  • Identify required equipment
  • Perform the Procedure
Cognitive Psychomotor
OOO OOO Ankle Arthroscopy
OOO OOO Ankle Cheilectomy
OOO OOO Ankle Arthrodesis
OOO OOO Ankle Arthroplasty
OOO OOO Lateral Ankle Ligament Reconstruction
OOO OOO Haglund/Retrocalcaneal Resection
OOO OOO Gastrocnemius Slide
OOO OOO Tendoachilles Lengthening
OOO OOO Calcaneal Osteotomy
OOO OOO Subtalar Arthrodesis
OOO OOO Triple Arthrodesis
OOO OOO Naviculocuneiform Arthrodesis
OOO OOO 1st Tarsometatarsal Arthrodesis
OOO OOO Lateral Column Lengthening
OOO OOO Lapidus Procedure for Hallux Valgus
OOO OOO Proximal Metatarsal Osteotomy for Hallux Valgus
OOO OOO Chevron Osteotomy for Hallux Valgus
OOO OOO Medial Capsulorraphy (1st TMT)
OOO OOO 1st MTP Cheilectomy
OOO OOO 2nd Metatarsal Shortening Osteotomy
OOO OOO 5th Metatarsal Rotational Osteotomy for Bunionette
Tendon Transfers
OOO OOO FDL to Posterior Tibial Tendon
OOO OOO Posterior Tibial Tendon to Dorsum
OOO OOO Peroneus Longus to Peroneus Brevis
OOO OOO FHL to Peroneus Brevis
OOO OOO Peroneus Longus to Achilles
OOO OOO FHL to Achilles
OOO OOO Extensor Substitutions
OOO OOO Girdlestone-Taylor Transfers (FDL to Dorsal Hood)
OOO OOO FHL to proximal phalanx of great toe
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