Surgical Care of the Lower Extremities

aaos.jpg(Statement of the American Academy of Orthopaedic Surgeons, March 2000; Endorsed by American Orthopaedic Foot & Ankle Surgeons, March 2000)

Increasingly, efforts are being made by some health care providers to expand their scope of practice beyond the limits of their education, training, and experience. State laws and local practice standards frequently do not take these limits into account when establishing law and credentialing standards. In many areas of the country, practitioners with inadequate training are performing reconstructive1 surgery despite the risk of harm to patients. This is a significant issue in reconstructive surgery on the foot, ankle, and lower extremities.

Critical issues for legislators and other decision-makers include:

Defining minimum qualifications for performing musculoskeletal reconstructive surgery on the lower extremities;

1. Requiring a level of education and training that is commensurate with the complexity of the surgery and potential risk to the patient;

2. Recognizing the role and importance of the accredited, post-doctoral surgical residency, and recognizing a uniform national surgical board certification process.

The American Association of Orthopaedic Surgeons ("AAOS") believes that it is in the best interests of public safety and good patient care to establish a basic set of qualifications for any health care provider performing musculoskeletal reconstructive surgery on the foot, ankle and lower extremities.

These minimum qualifications are:

  • Completion of a nationally-accredited, post-doctoral surgical residency program; and
  • Board certification, through examinations, from a Surgical Board recognized by the American Board of Medical Specialties2 or equivalent; and
  • State licensure.

The AAOS believes that orthopaedic surgeons are the most qualified providers of musculoskeletal patient care. Consistent with an orthopaedic surgeon's education, training and experience, this includes operative and non-operative foot and ankle care and reconstructive surgical care for all bones, joints, muscles and tendons of the lower and upper extremities, the spine, neck, pelvis and torso.

Orthopaedic surgeons are musculoskeletal specialists who can function as cost-effective3 primary care providers for foot and ankle care in any health care delivery model. Orthopaedic surgeons are physicians who, given their education and training, can recognize and respond effectively to serious medical complications which may arise and complicate the treatment of any disorders in the foot, ankle, and lower extremities.

Attributes of Board-Certified Orthopaedic Surgeons

Board-certified orthopaedic surgeons, and AAOS members, are medical doctors with the advanced degrees of "M.D." or "D.O.". They have completed a nationally accredited, post doctoral surgical residency program.

Orthopaedic surgeons in the U.S. become Board Certified through the American Board of Orthopaedic Surgery (ABOS).4 Approximately 96-98% of all Board-Certified orthopaedic surgeons become members of the AAOS.

The AAOS believes that any specialty or provider group seeking surgical privileges should have one national surgical board and a uniform certification process, with examinations, like that found in orthopaedic surgery. The AAOS believes, further, that the official surgical board should be recognized by the American Board of Medical Specialties, or equivalent, for the given specialty or provider group.

(See Appendix A for the Requirements for Board Certification, through the American Board of Orthopaedic Surgery.)

The Orthopaedic Surgery Residency

Orthopaedic Surgery residencies have always been five years long or four years, with a mandatory one year internship in a general medical specialty, such as general surgery, internal medicine or pediatrics before the orthopaedic surgery residency.

After July 1, 2000 all orthopaedic surgery residency programs will be five years long.

Requirements for Accreditation Council for Graduate Medical Education,5 "ACGME"-accredited, orthopaedic surgery residency programs are uniform throughout the United States.

The AAOS believes that any specialty or provider group seeking surgical privileges should, through its nationally-recognized accrediting body, possess uniform surgical residency requirements, and a system of accredited residency programs, leading to Board Certification, like that found in orthopaedic surgery.

(See Appendix B Program Requirements for Residency Education in Orthopaedic Surgery, from ACGME.)

Residency Program Attributes

To be accredited, an orthopaedic surgery residency must adhere to the guidelines and requirements of the Accreditation Council for Graduate Medical Education (ACGME) and its Residency Review Committee (RRC).6 The AAOS believes that the ACGME's requirements for orthopaedic surgery residency programs, and the role of the Residency Review Committee (RRC) in assuring compliance create a "gold standard" in musculoskeletal education and training.

(See Appendix C for ACGME Residency Program Attributes)

APPENDICES

Appendix A: Requirements for Board Certification, through the American Board of Orthopaedic Surgery (ABOS):

  • 5 years (60 months) in post-doctoral residency education, including 48 months in an orthopaedic surgery residency accredited by the Residency Review Committee (RRC)1 for orthopaedic surgery, and the Accreditation Council for Graduate Medical Education (ACGME)2 (prior to 7/1/2000 the orthopaedic surgery residency requirement is 36 months);
  • A full or unrestricted license to practice medicine in the U.S. or Canada;
  • Continuous and active engagement in the practice of operative orthopaedic surgery, beyond residency, for at least 22 months;
  • Passage of Part I (written exam) and Part II (oral exam) of the certifying exam
  • Passage of the qualifying exam in orthopaedic surgery of the Royal College of Physicians and Surgeons of Canada, if Canadian.

Appendix B: Program Requirements for Residency Education in Orthopaedic Surgery, from the Accreditation Council for Graduate Medical Education, "ACGME".

The First Year

In the five-year program, the first year (PGY-1) must include resident participation in clinical and didactic activities that provide opportunities for residents to

  • Develop the knowledge, attitudes and skills needed to assess, plan, and initiate treatment of adult and pediatric patients with surgical and/or medical problems;
  • Be involved in the care of patients with surgical and medical emergencies, multiple organ system trauma, soft tissue wounds, nervous system injuries and diseases, peripheral vascular injuries and diseases, and rheumatologic and other medical diseases;
  • Gain experience in the care of critically ill surgical and medical patients;
  • Participate in the pre-, intra-, and post-operative care of surgical patients; and develop an understanding of surgical anesthesia, including anesthetic risks and the management of intra-operative anesthetic complications. The first year must include a minimum of six months structured education in surgery, including multi-system trauma, plastic surgery, burn care, intensive care and vascular surgery.

Years Two through Five

Years two through five include the following:

  • All aspects of diagnosis and care of disorders affecting the bones, joints, and soft tissues of the upper and lower extremities, including the hand and foot; and the entire spine including inter-vertebral discs; and the bony pelvis.
  • Diagnosis and care, both operative and non-operative, of acute trauma, including athletic injuries, infectious disease, neurovascular impairment, and chronic orthopaedic problems, including reconstructive surgery, neuromuscular disease, metabolic bone disease, benign and malignant tumors, and rehabilitation.
  • Diagnosis and management of adult and pediatric orthopaedic disorders, including adult orthopaedics, joint reconstruction, pediatric orthopaedics, pediatric trauma, multi-system trauma, surgery of the spine, including disk surgery, spinal trauma and spinal deformities; and hand surgery;
  • Foot surgery in adults and children, athletic injuries including arthroscopy; metastatic disease; and orthopaedic rehabilitation, including amputations and post-amputation care.
  • Orthopaedic oncology, rehabilitation of neurologic injury and disease, spinal cord rehabilitation, orthotics and prosthetics, and the ethics of medical practice.
  • Substantial instruction in anatomy, biomechanics, pathology, and physiology; and embryology, immunology, pharmacology, biochemistry, and microbiology.
  • Instruction and experience in the proper use of surgical instruments and operative techniques.

Appendix C: Residency Program Attributes, from the Accreditation Council for Graduate Medical Education (ACGME) and the RRC (Residency Review Committee).

To be accredited, an orthopaedic surgery residency must adhere to the guidelines and requirements of the ACGME and its Residency Review Committee (RRC):

  • Each ACGME-accredited orthopaedic surgery residency program has a single sponsoring institution, which meets the ACGME Institutional Requirements.
  • Residency programs have a designated Program Director and at least 3 faculty, including 1 full-time faculty member to every 4 students. The Program Director is licensed to practice medicine in the state, Board-certified, and in good standing in the institution.
  • The Program Director and teaching staff prepare and comply with written educational goals for the program.
  • The Program Director provides a written final evaluation for each resident who completes the residency program. This verifies that the resident has demonstrated sufficient professional ability to practice competently and independently, and is part of the resident's permanent record.
  • The Residency Review Committee (RRC) approves the program design and structure, on a regular review basis.

1. Reconstructive surgery on the foot, ankle and lower extremities includes, but is not limited to, repair of fractures, amputations, replacement of joints, correction of bone and congenital deformity, fusion of joints, tendon repair and transfer.

2. American Board of Medical Specialties (ABMS): is the umbrella organization for the 24 approved medical specialty boards in the United States. ABMS coordinates the activities of Member Boards, like the American Board of Orthopaedic Surgery, and provides information to the public, the government, the profession and its Members concerning issues involving specialization and certification in medicine. The mission of ABMS is to maintain and improve the quality of medical care in the United States by assisting the Member Boards in their efforts to develop and utilize professional and educational standards for the evaluation and certification of physician specialists.

3. "Differences in Costs of Treatment for Foot Problems Between Podiatrists and Orthopedic Surgeons"; R.B. Harris, PHD; J.M. Harris, Jr., MD; J. Hultman, DPM; and S. Weingarten, MD, MPH; American Journal of Managed Care, Vol. 3, No. 10, 1997.

4. American Board of Orthopaedic Surgery (ABOS): a private, voluntary, non-profit, autonomous organization, which establishes educational standards for orthopaedic residents, reviews credentials and practices of candidates, and issues certificates. ABOS defines minimum educational requirements in the specialty, stimulates graduate medical education and continuing medical education, and aids in the evaluation of educational facilities and programs.

5. Accreditation Council for Graduate Medical Education (ACGME): is jointly sponsored by the American Board of Medical Specialties, the American Hospital Association, the American Medical Association, the Association of American Medical Colleges, and the Council of Medical Specialty Societies. ACGME develops and disseminates policies, procedures and guidelines for the accreditation of medical education programs, and is responsible for evaluating and accrediting residency programs within the U.S. Accreditation of graduate medical education programs is carried out, under the aegis of ACGME, through a number of review committees, like the Residency Review Committee for Orthopaedic Surgery.

6. Residency Review Committee (RRC) for Orthopaedic Surgery: an autonomous committee composed of three representatives from each of the three sponsoring organizations: the American Board of Orthopaedic Surgery, the Council on Medical Education of the American Medical Association, and the American Academy of Orthopaedic Surgeons. In evaluating orthopaedic residency programs, the RRC considers the number of residents, training period, program organization, educational experience, and institutional responsibility. Institutions offering orthopaedic education must meet the requirements of the ACGME and the RRC.

© March 2000 American Academy of Orthopaedic Surgeons This material may not be modified without the express written permission of the American Academy of Orthopaedic Surgeons.

Endorsed by AOFAS, March 18, 2000