Levels of Evidence for Foot and Ankle Questions on the Orthopaedic In-Training Examination: 15-Year Trends

BACKGROUND: The foot and ankle (FA) content domain is a component of the orthopaedic in-training examination (OITE). Levels of evidence (LoE) have been infrequently studied on the OITE. The purpose of this study is to determine if LoE for primary journal articles referenced for FA questions increased over a 15-year period. We also aim to determine if reference characteristics and question taxonomy have changed during this period. METHODS: All 132 questions and 261 references in the FA content domain from 1995 to 1997 and from 2010 to 2012 were included. We defined the characteristics of each reference and taxonomy of each question. Every primary journal article was assigned a LoE based on American Academy of Orthopaedic Surgeons (AAOS) guidelines. RESULTS: Foot & Ankle International (FA1) was the most frequently cited journal. The change in the distribution of the Buckwalter classifications was statistically significant (p = 0.0286) with an increase in the number of clinical management questions. There were more level I studies on the 2010 to 2012 OITE (p = 0.0478) 6/54 (11%) of questions on the 2010 to 2012 OITE cited level I or II evidence compared with 3/78 (4%) on the 1995 to 1997 examinations (p = 0.1035). CONCLUSIONS: There is a trend toward improved LoE for journal articles within the FA content domain on the OITE over a 15-year period, particularly when analyzing the increase in level I studies. FAT is the most frequently cited journal and questions increasingly test clinical management concepts. CLINICAL RELEVANCE: Our results can be used to help improve resident self-study and suggest that reviewing recent FAT articles may aid OITE preparation. LEVEL OF EVIDENCE: Basic Science ((C) 2016 Association of Program Directors in Surgery. Published by Elsevier Inc. All rights reserved.)