A Cross-Sectional Analysis of Foot and Ankle Fellowship Match From 2012 to 2023: Does Gender or Degree Type Matter?

Abstract

Background:

In recent years, there has been an increased push for diversity in orthopaedics at the residency level. There has also been a noticeable shift away from foot and ankle fellowship, with many fellowship positions open throughout the country annually. With the increase in osteopathic and female orthopaedic applications to orthopaedic surgery residency, we hypothesized that this would be reflected in the foot and ankle fellowship applications in the last decade.

Methods:

The San Franscisco Match data from 2012 to 2023 were analyzed for degree type and from 2013 to 2023 for gender. There were 1082 applicants for adult foot and ankle fellowships from 2012 to 2023, 74 osteopathic applicants (11.4%), and 573 allopathic applicants (88.6%). There were 126 female applicants (21.3%) and 465 male applicants (78.7%). The 435 international graduates were excluded from this analysis. The degree type, gender, number of applicants, and number of applicants matched into orthopaedic foot and ankle fellowship was reviewed.

Results:

The number of osteopathic applicants and female applications did not change significantly over the study period. There was a statistically significant decrease in the number of allopathic applicants (P = .003) and a significant decrease in the number of male applicants to foot and ankle fellowship (P = .00004). The match rate for allopathic, osteopathic, and male applicants all statistically increased over the study periods, whereas the female applicant match rate remained stable. Programs tended to rank their matched allopathic residents higher, whereas osteopathic applicants’ position in the fellowship program rank list remained steady. Female and male applicants matched at programs higher on their rank lists, whereas programs match applicants lower on theirs.

Conclusion:

More orthopaedic foot and ankle surgeons are needed nationwide. Understanding recent trends in applicant demographics and match outcomes may help inform strategies to increase interest and participation in this subspecialty.

Level of Evidence:

IV, cross-sectional study.

Introduction

Women and osteopathic (DO) surgeons have historically been underrepresented in the field of orthopaedics at all levels of training, from resident to the attending level. ⁵ Despite a push to diversify the specialty, it is one of the slowest to reduce the disparities in racial minority group and female representation. ³ Furthermore, the percentage of DOs matching into the specialty continues to decline. ¹⁵ This translates to the consistently small percentages of these groups practicing as attending physicians across the country. It is well established that diversity in the medical field broadens health care access, increases patient satisfaction, and improves trainee education. ¹¹ This also translates to the residency level, as higher-ranked orthopaedic surgery programs have been demonstrated to be more diverse. ¹

A recent study showed that of the 49 orthopaedic foot and ankle fellowship programs included, only 26.5% had at least 1 female faculty member. Of the 307 fellows identified over the 6-year study period, only 19.5% were women. ¹ Furthermore, these trends hold true at the leadership level. A study analyzing the gender and ethnic makeup of foot and ankle fellowship leaders/directors only supported this notion, with 95.6% of fellowship directors male, and 88.2% White. ¹⁶ To our knowledge, only 1 study has looked at the percentage of osteopathic trained physicians in Foot and Ankle fellowship. From the years 2016 to 2021, the highest percentage of osteopathic-trained fellows was 14.8% (2018), further declining in 2020 and 2021 (3.4 and 3.5%, respectively). ⁷

Therefore, the purpose of this study is to evaluate the trends in foot and ankle orthopaedic fellowship match rates in osteopathic vs allopathic applicants, as well as between male and female applicants. This is the first study to look at the match rates of both female and osteopathic applicants to foot and ankle fellowships. We hypothesize that numbers of osteopathic and female residents applying for foot and ankle fellowship have increased as the field attempts to diversify. We also hypothesize that match rates between men and women are comparable, whereas match rates among allopathic residents are higher compared with osteopathic because of historic bias.

Methodology

San Francisco Matching Service (SF Match, San Franscisco) data from 2012 to 2023 were collected; however, gender data were collected from 2013 to 2023. Although the SF Match database has previously been used to evaluate foot and ankle match data regarding osteopathic and female applicants, our study differs in that it collects data over a longer study period with the aim to report longitudinal trend data.^2,9 SF Match was used by foot and ankle fellowship during our study period for prospective applicants; however, this data set did not include residents who filled empty fellowship positions after the match was complete.

There were 1082 applicants for orthopaedic foot and ankle fellowships from 2012 to 2023. There were 74 osteopathic applicants (11.4%) and 573 allopathic applicants (88.6%). There were 435 (40.2%) international medical graduates who were excluded from this analysis. From 2013 to 2023, there were 126 female applicants (21.3%) and 465 male applicants (78.7%). The degree type, gender, number of applicants, and number of matched applicants into orthopaedic foot and ankle fellowship was reviewed. Trends regarding number of applicants and match rates based on applicant degree were evaluated.

Also analyzed was the average rank each matched applicant ranked for their corresponding matched fellowship, as well as the average ranking of the applicants matched by the fellowship. Statistical analysis was conducted of all data using 1 sample t test analyzing each trend over each time period. An alpha value of .05 was considered statistically significant.

Results

Overall, the number of US foot and ankle applicants significantly decreased over the study period, (r = −0.79, P = .0006). The number of osteopathic applicants ranged from a low of 2 in 2018 and 2019 to a high of 11 in 2016 (mean 6.2 ± 2.6) with no statistically significant change over the study period (r = −0.12, P = .34), seen in Figure 1A. The match rate for osteopathic applicants statistically increased from 75.0% (6 of 8) in 2013 to 100.0% (5 of 5) in 2023 (mean 91.2% ± 9.9%, r = 0.72, P = .003) (Figure 1B). For allopathic (MD) residents, the number of applicants ranged from a low of 37 in 2022 to a high of 63 in 2014 (mean 47.8 ± 6.9), with a significant decrease over the study period (r = −0.7, P = .003). The match rate for allopathic applicants ranged from a low of 88.0% (44 of 50) in 2013 to a high of 100.0% (37 of 37) in 2022 (mean 94.5% ± 4.5%). There was a statistically significant increase in the match rate of allopathic applicants over the study period (r = 0.79, P = .0007). Over the study period, there was no statistically significant difference in match rates between osteopathic and allopathic candidates (OR = 1.65, P = .31).

Figure 1.

(A) Gross number of osteopathic (DO) and allopathic (MD) foot and ankle fellowship applicants from 2012 to 2023. (B) DO and MD percentage match rates. (C) Female and male gross number of applicants from 2013 to 2023. (D) Gender percentage match rates from 2013 to 2023.

The ranking of osteopathic applicants by their respective matched fellowship had no statistically significant change (r = −0.14, P = .33), whereas the matched program rank by the osteopathic applicant was ranked significantly lower (r = 0.55, P = .03) over the study period. The ranking of allopathic applicants by their respective matched fellowships were ranked significantly higher (r = −0.72, P = .004) over the study period. During the same period, respective matched program rank was significantly lower (r = 0.69, P = .007) by the allopathic applicants.

The number of female applicants ranged from a low of 6 in 2013 to a high of 14 in 2023 (mean 11.5 ± 2.8), with no statistically significant change over the study period (r = 0.4, P = .086) (Figure 1C). The match rate for female applicants increased from a low of 76.9% (10 of 13) in 2017 to 100.0% (14 of 14) in 2022 (mean 92.1% ± 8.8%), with no statistically significant change over the study period (r = 0.45, P = .06) (Figure 1D). For male residents, the number of applicants ranged from a low of 32 in 2023 to a high of 58 in 2014 (mean 42.3 ± 8.0), with a significant decrease over the study period (r = −0.89, P = .00002). The match rate for male applicants ranged from a low of 86.5% (45 of 52) in 2013 to a high of 100.0% (32 of 32) in 2023 (mean 95.1% ± 4.9%). There was a significant increase in the match rate of male applicants over the study period (r = 0.95, P = .000002). Male applicants matched at a slightly higher rate than female applicants (95.1% vs 92.1%), although this difference was not statistically significant (OR = 1.46, P = .4).

Both female and male applicants were ranked significantly lower by their respective matched fellowship (r = −0.76, P = .001; r = −0.58, P = .02), respectively. Both female and male applicants ranked their matched fellowship programs significantly higher on their rank lists (r = 0.53, P = .03; r = 0.77, P = .001), respectively, during the study period.

Discussion

Despite increased interest in orthopaedic residency overall, foot and ankle fellowships have experienced a significant decline in applicant numbers over the last 11 years. ¹⁰ Although further qualitative research would be needed to understand this decline, as of January 2024, the American Orthopaedic Foot & Ankle Society (AOFAS) is advertising 16 open fellowship positions on their fellowship program website. This study’s aim was to analyze foot and ankle application trends among osteopathic and female applicants compared with allopathic and male counterparts, respectively.

We found that during the last 10 years, although there has been no significant change in osteopathic applicants, there has been a significant decline in allopathic applicants. This decrease in overall applicants may have led to the increase in the match rate of both allopathic and osteopathic applicants who applied that we saw during the study period. On average, allopathic applicants are matching to programs ranked higher on their rank lists, while programs are matching applicants lower on their rank lists. Osteopathic applicants have seen no change in the position of their matched program on their rank lists. Both osteopathic and allopathic applicants matched on average to their second-ranked program over the last 11 years.

There has been a large push for recruitment of women into orthopaedics in the last few years, reflected in the near doubling in female medical school applicants applying into orthopaedic surgery residency. ¹³ Although more and more residencies recognize the importance of diversity, there has only been a 3.3% increase in the amount of female orthopaedic surgery residents calculated from 2012 to 2020. ⁴ Naclerio et al ¹² found, of the fellowships that use the SF Match, foot and ankle had the second highest proportion of female applicants; however, although the gross number of female applicants applying to fellowships has slightly increased during the last decade, the number of female foot and ankle applicants has not.

Our study corroborates this finding while also finding a decrease in male applicants over our study period signaling a decrease in interest in the foot and ankle subspecialty. Both male and female applicants matched to programs higher on their rank lists, whereas programs were matching applicants lower on their lists. The overall decrease in applicants, especially among male residents, may allow applicants to be more selective over their top 3 ranked programs, whereas programs may be competing over the same applicants.

This decrease in overall applications to the foot and ankle subspecialty is leading to many open fellowship positions and a desperate need for more orthopaedically trained foot and ankle surgeons nationwide. Although this study did not address the causation to this decline and is only hypothesized within this study, the prevalence and expansion of podiatric medicine to fill this gap in foot and ankle care cannot be ignored. Another possible cause of decline in application is the large variation of foot and ankle exposure between the 10th and 90th resident percentiles seen in case documentation reported by the Accreditation Council for Graduate Medical Education (ACGME). ⁶ It has previously been found that only 47.5% of graduating residents feel comfortable independently performing arthrodesis in the ankle, hindfoot, and midfoot, with the only other surgical procedures with lower confidences being spinal decompression and fusions (16.1%). ⁸

With this incredible variation of exposure from program to program, mentorship, whenever possible, especially interinstitutional mentorship, will need to be prioritized in order to reverse these trends. The AOFAS has started a Resident Scholarship program, which helps residents interested in foot and ankle travel to the national conference; however, more mentorship programs are needed to spur interest in this dynamic and progressing field of orthopaedics.

The limitations of this study include the limitations of this data set (ie, demographics) provided by SF Match. We were unable to break down data into female MD vs DO and male MD vs DO because of the unavailability of the data. We use the term gender in this article in terms of how applicants self-identified on their applications. We are unable to verify whether this selection is truly how the individual presents or self-identifies. Moreover, we were also unable to assess intersectional differences, such as female vs male DO applicants, because of limitations in the data provided by SF Match.

Another limitation was the lack of data available for analysis. Although the SF match started in 2010 for orthopaedic surgery, we were only able to obtain match data from 2012 to 2023, with gender specification starting in 2013. The 2010 to 2011 data were not available for analysis. Although the first foot and ankle fellowships began in the late 1900s, these data only address recent trends within the past 12 to 13 years.

Additionally, because of the small changes seen from year to year, as well as the descriptive nature of the analytics, this study is not without biases. Because of the limited size and retrospective cross-sectional nature of the data set, this study has limited predictive power; therefore, we are unable to anticipate future trends. This study did not include any qualitative data in order to draw conclusions regarding causations of certain trends. All possible causes of trends discussed are hypothesized by the authors.

Future research should include more quantitative questioning in order to attempt to understand the decrease of resident applications into foot and ankle fellowships. According to reports published by the American Association of Colleges of Podiatric Medicine (AACPM), in 2024, a total of 569 podiatrists graduated their residency, whereas fewer than 100 surgeons annually graduate from orthopaedic foot and ankle fellowships every year. ¹⁴ More research is necessary to understand why orthopaedic residents continue to shy away from foot and ankle fellowships and what can be done to increase exposure and improve application numbers into the specialty. This should include both qualitative and quantitative surveys to study the rationale of why residents pick certain specialties and what aspects of the fields are important to them.

Conclusion

More orthopaedically trained foot and ankle surgeons are needed throughout the country; however, we found that there has been a decrease in US resident applications to foot and ankle fellowship over the last decade. Additional programing to familiarize and encourage residents to pursue foot and ankle as a specialty, such as the AOFAS Resident Scholarship Program, is desperately needed for recruitment across the country. Although we found that allopathic and male applications have significantly decreased during the study period, this recruitment should be aimed at all residents. Foot and ankle pathologies can have debilitating morbidity for patients, and more qualified orthopaedic foot and ankle surgeons are needed across the nation to care for these patients, but this needed increase must start with recruitment at the residency level.