Variability in the Orthopaedic Residency Trainee Trauma Surgical Experience

Abstract

Background:

The aim of this study was to analyze fracture fixation case logs from residents training at a level 1 trauma center to assess variability across residents' surgical experiences within a single residency program. The authors hypothesize that notable variability exists between residents' surgical experiences in fracture care.

Methods:

A retrospective case series was conducted at a single, urban residency program with a level 1 trauma center. Completed case logs were collected from program graduates from 2022 to 2024. All surgical cases involving fracture fixation at the level 1 trauma center were included for analysis. The anatomic region of the fracture surgery was determined by translating the case log current procedural terminology (CPT) code entry into the corresponding “bone” and “segment” per the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association fracture classification system. For external validation and generalizability, resident cases were compared with those from a recent multicentered epidemiologic study using a two-proportion z-test. Variations in resident case logs were tested using analysis of covariance.

Results:

A total of 4,616 fracture fixation cases were identified across the 14 graduate case logs. The average number of fracture cases per resident was 329.7 (SD = ±80.3). No significant difference was observed in resident surgical experience at the home institution when comparing the anatomic region of the fracture surgery (P = 0.189). When compared with a multicenter epidemiologic study, our institution had significantly fewer proximal femur fractures (P < 0.001) and significantly more ankle fractures (P < 0.001).

Conclusion:

While assuring consistency of clinical experience within orthopaedic resident training is an exceptionally difficult task, it seems that residents in this program received similar exposure to varying fracture trauma pathologies. However, there may exist regional differences or other variables that contribute to differences in fracture location and/or volume from one institution to another. It remains essential for residents to take an active role in ensuring that they gain sufficient surgical volume to achieve clinical competence.

Each orthopaedic residency is unique and varies from other residency programs in numerous ways, including locale, the number of residents, the number of clinical sites, the length of rotations, and the fraction of training time spent exploring individual subspecialties. To ensure consistency in program training, the American Council for Graduate Medical Education (ACGME) has set forth standards for training programs, with the latest update as of July 1, 2023. The first set of standards focuses on the time line of orthopaedic residency, enforcing minimums for on-versus-off service orthopaedic rotations and requirements for length of time spent on each rotation. The second set of standards outlines surgical case volume requirements, discusses the breadth and variety of cases, and establishes minimum thresholds for participation in specific cases to ensure a comprehensive training experience.

Although the guidelines aim to achieve consistency across programs and ensure readiness for postresidency practice, they encapsulate a broad array of surgical procedures, comprising a wide variety of challenges and learning curves, which can influence the level of proficiency and clinical competency among graduates.^1-3 Despite efforts to standardize certain aspects of orthopaedic training, inter-residency variability inherently exists. Previous analyses of resident case logs have demonstrated substantial variability in exposure to arthroplasty, spine surgery, and orthopaedic trauma surgery.^3-5 This study is unique in that it specifically analyzes fracture case logs among orthopaedic trauma cases and enables a comparison with previous fracture case log literature. While each resident seems to be meeting the ACGME minimum requirement for specific orthopaedic cases, understanding these variances in surgical exposure is necessary to ensure well-rounded resident training and best prepare residents for future scopes of practice.

Attempts to ensure adequate training volume and variety are necessary for multiple reasons. Primarily, surgical comfort level is closely tied to the volume and complexity of training cases, with increased exposure leading to greater proficiency.^6,7 Moreover, factors related to training environment, hospital infrastructure, and patient population may expose residents to differing levels of complex fracture care or rare pathology encounters, which can lead to differences in residents' perceived readiness for clinical practice. Thus, as measures of resident competency begin to shift from case-based minimums to more experiential measures, consistency and availability of cases are crucial to maintaining a well-rounded breadth and depth of orthopaedic surgery training; however, reducing variability in case exposure within orthopaedic resident training is an exceptionally difficult task between resident rotation schedules and orthopaedic trauma volume variation. The aim of this study was to analyze the variation in fracture fixation case logs among residents training at a level 1 trauma center to assess variability in residents' surgical experiences. The authors hypothesize that rotation schedules would lead to notable disparities in residents' surgical experiences, especially in less frequently encountered fractures.

Methods

A retrospective case series was conducted at a single, urban residency program with multiple clinical sites and a level 1 trauma center. The design of this residency program is such that each resident completes the same number of months of rotations at the level 1 trauma center during his/her residency. Completed case logs from graduates were collected from 2022 to 2024, encompassing three graduating classes. All surgical cases involving fracture fixation at the level 1 trauma center were included for analysis. Open fracture débridement, irrigation and débridement, wound vacuum placement, external fixator placement, soft-tissue procedures, and implant removal procedures were excluded. All cases from other clinical sites were excluded, including a level 1 pediatric trauma center, a Veteran's Affairs Medical Center, and other private hospitals. Case logs were extracted, and the anatomic region of the fracture surgery was determined by translating the associated CPT code in the case log entry into the corresponding “bone” and “segment” per the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association (AO/OTA) fracture classification. For external validation and generalizability, the proportions of specific fracture cases for each resident were compared with those of a recent large, multicentered national epidemiologic study on orthopaedic fracture cases, which was similarly stratified according to the AO/OTA fracture classification.⁸ This study consisted of 5,324 adult patients diagnosed with at least one fracture, for a total of 5,865 fractures included in the analysis.⁸

Descriptive statistics were used to analyze differences between resident case logs and a large, multicentered epidemiologic study.⁸ A two-proportion z-test was used to compare proportional data. Variability across resident case logs was tested using analysis of covariance to evaluate whether the means of cases recorded for each resident, when stratified by AO/OTA classification, were equal. Alpha was set to a significance level of 0.05 for all analyses. Statistical analyses were conducted with IBM SPSS Statistics V.28.0 (IBM) and R software 3.6.1 (www.r-project.org).

Results

In total, case logs for 14 of the 18 graduates were procured, whereas the remaining four case logs could not be obtained by the corresponding graduates. A total of 4,616 fracture fixation cases were identified at the level 1 trauma center among the 14 participants. The mean number of trauma cases per resident was 329.7 (SD = ±80.3), with ankle fractures (AO/OTA 44) representing the most common case and scapula fractures (AO/OTA 14) and carpal fractures (AO/OTA 71 to 76) representing the least common cases. Percent distribution of cases by anatomic region for all residents in this study is presented in Figure 1. Figure 2 shows the average number of cases, with 95% confidence intervals, stratified by AO/OTA classification.

Figure 1.

A pictorial representation of the Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association fracture classification system, as well as the surgical fracture cases performed by residents in this study.

Figure 2.

Plot demonstrating the mean number of cases stratified by Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association classification across orthopaedic residents with 95% confidence intervals.

Variance Among Resident Experiences

Using an analysis of covariance test with individual resident as the independent variable, the number of fracture cases per AO/OTA classification as the dependent variable, and the total number of fracture cases per resident as the covariate, no significant difference was found in resident surgical experience (P = 0.189) when comparing the logged surgical experience of residents stratified by AO/OTA classification.

Generalizability

Figure 3 illustrates the differences between this study cohort and the reference cohort from Bilge et al.⁸ Noticeably, this study had significantly fewer proximal femur (P < 0.001), distal femur (P = 0.002), distal humerus (P < 0.001), and hand (P < 0.001) fractures and significantly more ankle (P < 0.001), midshaft radius (P = 0.045), distal radius (P < 0.001), proximal tibia (P < 0.001), and pelvic (P < 0.001) fractures, as given in Table 1.

Figure 3.

Bar graph comparing the mean percentage of surgical cases performed in each Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association category between the study by Bilge et al and this study. ***Statistically significant.

Table 1.

Percentage of Total Fractures Stratified by Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association Classification Between Study Cohort and Reference Cohort

AO/OTA Classification	Total Cases (%) in This Study	Total Cases (%) in the Study by Bilge et al	P Value
11	92 (1.99)	60 (2.15)	0.646
12	140 (3.03)	71 (2.54)	0.223
13	58 (1.26)	88 (3.15)	<0.001
14	8 (0.17)	2 (0.07)	0.250
15	48 (1.04)	39 (1.40)	0.165
21	186 (4.03)	102 (3.66)	0.418
22	219 (4.74)	104 (3.76)	0.046
23	407 (8.82)	136 (4.88)	<0.001
31	385 (8.34)	514 (18.43)	<0.001
32	325 (7.04)	208 (7.46)	0.503
33	92 (1.99)	87 (3.12)	0.002
34	95 (2.06)	45 (1.65)	0.211
41	260 (5.63)	103 (3.72)	<0.001
42	372 (8.06)	238 (8.53)	0.472
43	134 (2.90)	60 (2.15)	0.050
44	842 (18.24)	195 (6.99)	<0.001
5	191 (4.14)	93 (3.33)	0.080
6	382 (8.28)	86 (3.09)	<0.001
7	183 (3.96)	461 (16.51)	<0.001
8	197 (4.27)	95 (3.41)	1.849

The bold entries represent statistically significant differences (p < 0.05).

AO/OTA = Arbeitsgemeinschaft für Osteosynthesefragen/Orthopaedic Trauma Association

Discussion

This study sought to analyze the variability across residency graduate case logs stratified by AO/OTA classification at a level 1 trauma center at a single institution. We hypothesized that notable variability would exist across residents' surgical experiences, especially in less frequently encountered fractures; however, this study found no significant difference in case logs among 14 residency graduates between 2022 and2024.

Achieving consistency within orthopaedic resident training is an exceptionally difficult task; the time of year a resident rotates on trauma and the natural variation in orthopaedic trauma volume are among numerous factors that contribute to variability in trainees' clinical experiences. The ACGME has attempted to address this problem by instituting case-based minimums for specific orthopaedic fracture cases and monitoring these using a case log system to standardize the recording of surgical experiences for residents.³ However, since their implementation, studies have analyzed these case logs and found notable variability regarding both adult and pediatric orthopaedic surgeries among residents.^2,9

Our study demonstrates that although there is variance that naturally occurs among residents, the proportion of fracture cases to which residents are exposed does not markedly differ in the single residency program studied. This study has important implications regarding the future of orthopaedic surgery education, such that while residents within a single program receive similar fracture exposure, it is important for residents and program directors to know which potential surgical fracture experiences may be encountered less frequently within the said program. This idea aligns with the American Board of Orthopaedic Surgery's move toward implementing initiatives, such as the Knowledge, Skills, and Behavior Program, aimed at facilitating easy and accurate logging and obtaining formative feedback from faculty members to ensure that residents are receiving an adequate depth of training across a wide array of fracture types. While broader data from many orthopaedic residency programs of differing designs and environments would be optimal to further support these findings, the results suggest that initiatives aimed at ensuring adequate rotation lengths and time on service may be sufficient to ensure a consistent fracture case experience among residents.

Within the current literature, there is a lack of institutional data to compare with the results of our study. As a result, a study from another level 1 trauma center with recorded epidemiologic data for adult fracture cases by AO/OTA classification was used as reference. Our institution had markedly fewer proximal femur and distal femur fractures, which may be due to regional differences in trauma allocation by emergency medical services, as well as the home institution having a Veteran's Affairs Medical Center and private hospital that serve as the main sites for resident exposure to geriatric hip and distal femur fractures. Furthermore, demographic factors related to patient population and geographic factors that affect mechanism of trauma may play a notable role in exposure to various fracture morphologies. Hospitals in cold-weather climates may have more slip-and-fall accidents related to icy terrain, and regions with a higher proportion of geriatric residents may treat more fragility fractures. Our institution treated fewer hand fractures. Part of this deviation may be explained by the division of hand call among multiple services, whereas another may be stricter guidelines for nonsurgical or ambulatory management given limited operating room availability in a level 1 trauma center. The increased proportion of proximal tibia and pelvic fractures is likely due to the scope of a level 1 trauma center compared with the total epidemiologic data used within the study by Bilge et al. Finally, because our institution's level 1 center serves as a safety net hospital for the county, many ankle fractures and distal radius fractures are encountered, explaining the differences observed. Comparatively, the observed differences in proximal femur, ankle, and hand fractures may be explained by institutional and regional differences, whereas the others may fall within an acceptable variance for a single center.

This study is not without limitations. This analysis was retrospective and subject to inherent biases and confounders including regional bias, information bias, and systematic bias. The case log data were also subject to recall bias from residents comprehensively and accurately recording the details of each case. Residents may not accurately record all the cases they were involved in or may assign an incorrect CPT code by mistake. The data source is a single level 1 trauma center, while most programs have multiple training sites for resident case accrual.

Conclusion

While assuring consistency of clinical experience within orthopaedic resident training is an exceptionally difficult task, it seems that residents in this study received similar exposure to varying fracture trauma pathologies. However, there may exist regional differences between programs or other variables that contribute to differences in fracture location and/or volume from one institution to another. While data suggest that residents within a single residency program are effectively receiving equitable fracture case experiences, it remains essential for residents to take an active role in ensuring that they gain sufficient surgical volume to achieve clinical competence.