FOOT and ANKLE ROTATION-SPECIFIC OBJECTIVES PATIENT CARE Residents must be able to provide patient care that is compassionate, appropriate, and effective for the treatment of health problems and the promotion of health. Residents are expected to: • • • • • • • •

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Communicate effectively and demonstrate caring and respectful behaviors when interacting with patients and their families. Gather essential and accurate information about 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. Learn to incorporate various UCSD system resources such as PCIS, EPIC, and PACS to improve and expedite patient care. 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 Able to effectively: 1. Perform a general evaluation of outpatients with foot and ankle complaints with appropriate history and physical examination. 2. Perform a proper evaluation of the diabetic foot. 3. Perform a biomechanical examination of the foot and ankle with appropriate use of joint specific terminology. 4. Order appropriate radiographs and other studies to begin the evaluation of foot and ankle problems, including weight bearing views. 5. Interpret foot and ankle radiographs, CT scans, and MRI’s. 6. Develop a differential diagnosis of common presenting complaints of the ankle, hindfoot, midfoot, and forefoot. Develop clinical competency in the following procedures: 1. Safe surgical exposure to common foot and ankle problems. 2. Common osteotomies of the forefoot. 3. Aspiration and injection of foot and ankle joints. 4. Acute management of diabetic foot infection. 5. Acute management of neuropathic arthropathy. 6. Competency in foot and ankle arthrodesis techniques. 7. Correction of lesser toe deformities. 8. Local and regional anesthesia for foot and ankle surgery. 9. Rheumatoid forefoot reconstruction. 1

10. 11. 12. 13.

Rehab protocol for tendon ligament reconstructions of the foot and ankle. Rehab protocol for arthrodesis and procedures of the hindfoot and ankle. Rehab protocol for tendon ligament reconstructions of the foot and ankle. Rehab protocol for arthrodesis and procedures of the hindfoot and ankle.

General Patient Assessment Skills In a patient presenting with a complaint related to the foot or ankle the resident will demonstrate competency in the following skills: • Obtaining a focused Patient History • Performing an appropriate Physical Examination • Demonstrate an understanding of basic gait assessment • Perform aspirations and injections • Order and appropriately interpret relevant x-rays that may include: o AP Ankle o Ankle Mortise o Lateral Ankle o AP Foot o Lateral Foot o Oblique Foot o Reverse Oblique Foot o Axial Heel o Sesamoid View • Know the indications and basic interpretation of the following studies: o CT Scan o MRI o Bone Scan o Stress View X-rays o Fluoroscopy o Ultrasound o Non-invasive Vascular Studies o Electrodiagnostic Studies o Bone Mineral Density Studies • Know the indications and basic interpretation of the follow laboratory studies: o CBC o CMP o HgbA1c o ESR o CRP o RF o ANA Assessment and Treatment of Specific Conditions For the specific foot and ankle conditions listed below the resident will: •

Make an accurate diagnosis 2

• • • • • • • • • • •

Competently perform any relevant condition-specific physical examination Identify appropriate radiographic imaging studies Outline the etiology, or possible etiologies, of the specific condition Outline the natural history of the specific condition Describe appropriate non-operative treatment options, including cast management, bracing, orthotics, taping, prosthetics, and custom shoe management. Describe appropriate operative treatment options (if they exist) Describe appropriate post-operative treatment (antibiotic coverage, DVT prophylaxis, weight-bearing status) Understand appropriate anesthesia management, including local, general, spinal, epidural, regional, and monitored anesthesia care. Describe possible complications of non-operative and operative treatment Outline the prognosis of non-operative and operative treatment Perform appropriate documentation and coding for ambulatory/hospital/surgical care.

Specific Foot and Ankle Conditions (Chronic): • • • • • • • • • • • • • • • • • • • • • • • •

Ankle Osteoarthritis Osteochondral Lesion of the Talus Chronic Ankle Instability Achilles Tendonitis Retrocalcaneal Bursitis / Haglund's deformity Subtalar Arthritis Tarsal Coalition Peroneal Tendonitis Drop Foot Plantar Fasciitis Adult Flatfoot Deformity Posterior Tibial Tendon Dysfunction Accessory Navicular Cavovarus Foot Tarsometarsal/Midfoot Arthritis Hallux Valgus Hallux Rigidus Metatarsalgia Crossover Toe Deformity Morton’s Neuroma Claw/Hammer/Mallet Toes Bunionette Ingrown Toenail Diabetic Foot Ulcer

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Specific Foot and Ankle Conditions (Acute): • • • • • • • • • • • • •

Achilles Tendon Rupture Ankle Fracture Ankle Sprain Talar Body Fracture Talar Neck Fracture Calcaneal Fracture Navicular Stress Fracture Midfoot Fractures Lisfranc Fracture / Dislocation th Base of 5 MT Fracture Metatarsal Fracture Phalangeal Fractures Subungal Hematoma

Principles of Assessing and Treating General Foot and Ankle Problems For the general or systemic problems listed below the resident will: • • • •

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

General Foot and Ankle Problems • Diabetes • Charcot-Marie-Tooth • Cerebral Palsy • Rheumatoid Arthritis / Inflammatory Arthritis • Spinal Cord Injuries • Peripheral Neuropathies • Fungal Infections • Chronic Pain Syndrome • Reflex Sympathetic Dystrophy • Osteoporosis • Cigarette Smoking • Worker’s Compensation Issues Surgical Skills For the basic surgical skills listed below the resident will: •

Demonstrate competence in performing the described task. 4

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Appreciate the pitfalls and possible complications: o Surgical Planning o Prepping and Draping o Use of a Tourniquet o Choice of suture material o Suture tying o Regional Anesthetic blocks o Local Anesthetic blocks o Application of Short Leg Splint /cast o 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 OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO

Psychomotor OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO OOO

Tendon transfers: OOO OOO OOO OOO

Ankle Arthroscopy Ankle Cheilectomy Ankle Arthrodesis Ankle Arthroplasty Lateral Ankle Ligament Reconstruction Haglund's / Retrocalcaneal Resection Gastrocnemius Recession Tendoachilles Lengthening Gastrocnemius Recession Calcaneal Osteotomy Subtalar Arthrodesis Triple Arthrodesis Naviculocuneiform Arthrodesis st 1 Tarsometatarsal Arthrodesis Lateral Column Lengthening Lapidus Procedure for Hallux Valgus Proximal Metatarsal Osteotomy for Hallux Valgus Chevron Osteotomy for Hallux Valgus st 1 MTP Cheilectomy nd 2 Metatarsal Shortening Osteotomy th 5 Metatarsal Rotational Osteotomy for Bunionette

FDL to Posterior Tibial Tendon Posterior Tibial Tendon to Dorsum of Foot 5

OOO OOO OOO OOO OOO

OOO OOO OOO OOO OOO

Peroneus Longus to Peroneus Brevis FHL to Peroneus Brevis FHL to Achilles Extensor Substitutions Girdlestone-Taylor Transfer (FDL to Dorsal Hood)

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. • A weekly review of the core topics in Orthopaedic Foot and Ankle Surgery will be held. • Surgery of the Foot and Ankle by Coughlin, Mann, and Salzmann will be used as a basis for the conference, in addition to the review of landmark papers. • Orthopaedic In-Training Examination review • Successfully complete the Foot and Ankle Reading Reference List. • Demonstrate satisfactory knowledge of foot and ankle anatomy and biomechanics. • Demonstrate knowledge of etiology, path of mechanics, and surgical options for the various forms of hallux valgus deformity. • Appreciate treatment and algorithm for diabetic foot ulcers and neuropathic arthropathy.

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 health care professionals • Attend and participate in the weekly Foot and Ankle chapter review 6

• • • •

Attend and participate in the Foot and Ankle Journal Clubs with community foot and ankle surgeons Able to locate, appraise, and assimilate evidence from past and ongoing scientific studies related to individual patient and pathology. Able to obtain and use information about his/her patient population and the larger patient population from which patients are drawn. Able to use information technology to manage information access

INTERPERSONAL AND COMMUNICATION SKILLS Resident will at all times demonstrate behavior that is beyond reproach. Residents must be able to demonstrate interpersonal and communication skills that result in effective information exchange and teaming with patients, their patients 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. • Write an effective and timely consultation note that summarizes the findings and recommendations of the foot and ankle specialist and clarifies the continued involvement of the consultant • Work effectively with others as a member of a health care team

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: • Adheres to high ethical principles in the practice of medicine including confidentiality of patient information and informed consent. • Displays sensitivity and responsiveness to diverse patient cultures and backgrounds while working at a university-based clinic as well as a private outpatient clinic and with respect to culture, age, gender, socioeconomic backgrounds and disabilities. • Demonstrates respect, compassion, and integrity and responsiveness to patient needs. • Complies with hospital/operating room standards and guidelines including medical records. • Treats ancillary staff appropriately and with respect. • Demonstrate sensitivity and responsiveness to patients’ culture, age, gender, and disabilities

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SYSTEMS-BASED PRACTICE Residents must demonstrate an awareness of and responsiveness to the larger context and system of health care 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, including patients who are underfunded and nonfunded. This includes obtaining social work and case work consultations. • 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. • Communicate with other services (i.e. general surgery, vascular surgery, other consultant services), when indicated, including appropriate consultations and/or referrals and appropriate general medical health promotion and education. This is most important in patients with diabetic complications and vascular pathology.

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