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.
SilvestreJNelsonCLThompsonTLKangJD.Trends in ACGME accreditation of orthopedic surgery fellowship training. Orthopedics. 2023;47(1):57-63.
3.
HamidKSNunleyJA.Quo vadis? Perspectives on the future of foot & ankle fellowship training. Foot Ankle Int. 2016;37(10):1146-1148.
4.
HamidKSNunleyJA.A longitudinal analysis of 25 years of foot & ankle fellowship training. Foot Ankle Orthop. 2016;1(1):S00113.
5.
SchillerJRDiGiovanniCW.Foot and ankle fellowship training: a national survey of past, present, and prospective fellows. Foot Ankle Int. 2008;29(1):34-41.
YinHAnYDongL.Surgeon case volume and the risk of complications following surgeries of displaced intra-articular calcaneal fracture. Foot Ankle Surg. 2022;28(7):1002-1007.
8.
ZhuYChenWQinSZhangQZhangY.Surgeon volume and risk of deep surgical site infection following open reduction and internal fixation of closed ankle fracture. Int Wound J. 2022;19(8):2136-2145.
9.
WeinraubGMNewportIKimBKZhuSPatelS.Outcomes following open reduction internal fixation of ankle fractures (ORIF) by Podiatric surgeons. J Foot Ankle Surg. 2021;60(5):960-963.
WaltonRTheodoridesAMolloyAMellingD.Is there a learning curve in foot and ankle surgery?Foot Ankle Surg. 2012;18(1):62-65.
12.
MaccarioCTanEWDi SilvestriCAIndinoCKangHPUsuelliFG.Learning curve assessment for total ankle replacement using the transfibular approach. Foot Ankle Surg. 2021;27(2):129-137.
13.
ClementRCKrynetskiyEParekhSG.The total ankle arthroplasty learning curve with third-generation implants: a single surgeon’s experience. Foot Ankle Spec. 2013;6(4):263-270.
14.
JowettCRJBediHS.Preliminary results and learning curve of the minimally invasive chevron akin operation for hallux valgus. J Foot Ankle Surg. 2017;56(3):445-452.
15.
BediHHickeyB.Learning curve for minimally invasive surgery and how to minimize it. Foot Ankle Clin. 2020;25(3):361-371.
GurgaczSLSmithJATruskettPGBabidgeWJMaddernGJ.Credentialing of surgeons: a systematic review across a number of jurisdictions. ANZ J Surg. 2012;82(7-8):492-498.
18.
UrbachDR.Pledging to eliminate low-volume surgery. N Engl J Med. 2015;373:1388-1390.
19.
OttesenTDPathakNMercierMR, et alComparison of differences in surgical complications between fellowship-trained orthopedic foot and ankle surgeons and all other orthopedic surgeons using the ABOS database. Orthopedics. 2023;46(4):e237-e243.
20.
BarfieldMJacksonJB3rdGonzalezT.A cost analysis of ankle fractures treated by orthopedic surgeons with or without foot and ankle fellowship training at ambulatory surgery centers and hospitals. SAGE Open Med. 2022;10:128690.
21.
PattersonJTCampbellSTWallaceSJ, et alTriceps surae lengthening in foot and ankle trauma: a survey of OTA and AOFAS members. Foot Ankle Orthop. 2022;7(3):126719.
22.
ParisienRLTrofaDPGualtieriAP, et alHow do sports medicine and foot and ankle specialists treat acute achilles tendon ruptures?Foot Ankle Spec. 2021;14(2):114-119.
PanchbhaviVKAronowMSDigiovanniBF, et alFoot and ankle experience in orthopedic residency: an update. Foot Ankle Int. 2010;31(1):10-13.
25.
HartnettDALamaCJGarcia-LopezEDanielsAHRichardsonDR. Volume and variability of foot and ankle case exposure during orthopaedic residency: 2014-2019. Foot Ankle Spec. 2024;17(5):479-485.
26.
DeFrodaSFGilJABlankenhornBDDanielsAH.Variability in foot and ankle case volume in orthopaedic residency training. Foot Ankle Spec. 2017;10(6):531-537.
27.
ChanJJChanJCPoeranJZubizarretaNMazumdarMVulcanoE.Surgeon type and outcomes after inpatient ankle arthrodesis and total ankle arthroplasty: a retrospective cohort study using the nationwide premier healthcare claims database. JBJS. 2019;101(2):127-135.
28.
ChanJYTruntzerJNGardnerMJBishopJA.Lower complication rate following ankle fracture fixation by orthopaedic surgeons versus podiatrists. JAAOS: J Am Acad Orthop Surg. 2019;27(16):607-612.
29.
AllenCYoungerAVeljkovicAGlazebrookM.Orthopedic versus podiatric care of the foot and ankle: a literature review. Orthop Clin North Am. 2021;52(2):177-180.
30.
HarrisRBHarrisJMJrHultmanJWeingartenS.Differences in costs of treatment for foot problems between podiatrists and orthopedic surgeons. Am J Manag Care. 1997;3(10):1577-1583.
31.
HijjiFYGoodwinTMSichMA, et alA survey analysis of patient understanding and preferences for podiatrists versus foot and ankle orthopaedic surgeons. Foot Ankle Spec. 2025;18(1):97-107.
32.
KrausJNielsenALawBShiGWhealyG. Understanding patient preference of providers to treat foot and ankle disorders. Clin Med Res. 2022;20(1):40-45.
33.
SilvestreJThompsonTLWilsonRHNelsonCL.Surgical benchmarks for ACGME-accredited adult reconstructive orthopaedic fellowship training. J Am Acad Orthop Surg. 2022;30(20):999-1004.
34.
SilvestreJWuHHThompsonTLKangJD.Utility of spine surgery fellowship training for orthopaedic surgeons in the United States. J Am Acad Orthop Surg. 2023;31(7):335-340.
35.
ButlerBALawtonCDJohnsonDJNicolayRWYamaguchiJTStoverMD.The experiential benefit of an orthopedic trauma fellowship: an analysis of ACGME case log data from 2006 to 2017. J Surg Educ. 2019; 76(6):1556-1561.
36.
SilvestreJUptonJChangBSteinbergDR.The impact of specialty on cases performed during hand surgery fellowship training. JBJS. 2018;100(5):e29.
37.
SilvestreJFlynnJMThompsonTLOetgenME.Case volume benchmarks during residency and fellowship training for pediatric orthopedic surgeons. Cureus. 2022;14(12):e32738.
38.
SilvestreJNelsonCLKellyJD4thThompsonTL.Impact of COVID-19 on the reported case volume of orthopaedic sports medicine fellows in the United States. Orthop J Sports Med. 2023;11(2):149061.
39.
SilvestreJAhnJMehtaSHarrisMB.Impact of the SARS-CoV-2 outbreak on ACGME-accredited orthopaedic trauma fellowship training. Injury. 2023;54(12):111137.
40.
SilvestreJThompsonTLNelsonCL.The impact of COVID-19 on total joint arthroplasty fellowship training. J Arthroplasty. 2022;37(8):1640-1644.
41.
SilvestreJThompsonTLFlynnJM.Nationwide effect of COVID-19 on cases performed during pediatric orthopaedic surgery fellowship training in the United States. J Am Acad Orthop Surg. 2024;32(2):92-97.
OkikeKBergerPZSchoonoverCO TooleRV.Do orthopaedic resident and fellow case logs accurately reflect surgical case volume?J Surg Educ. 2018;75(4):1052-1057.
44.
SalazarDSchiffAMitchellEHopkinsonW.Variability in accreditation council for graduate medical education resident case log system practices among orthopaedic surgery residents. JBJS. 2014;96(3):e22.
