Foot and Ankle is the first of a series entitled Orthopaedic
Surgery Essentials. The editors of this series, Dr. Paul Tornetta, III
and Dr. Thomas A. Einhorn, have a wonderful vision for this compendium of
clinical orthopaedics: "to create a series at the basic level that
residents could read completely during a subspecialty rotation." The
logic is compelling and the task is daunting because, as anyone in a
multi-tiered educational system knows, it is a challenge to determine the
correct level of discussion for residents, and it is even more difficult to
decide how to compensate for the differences between rotations among the 159
orthopaedic residencies in the United States.
The fundamental unit of resident learning and teaching in the United States
is the subspecialty rotation, and it is now mandated by the Residency Review
Committee that rotation-specific objectives be created by each program, in
compliance with a national standard. The methods of evaluation of the
subspecialty knowledge base traditionally have been the Orthopaedic
In-Training Examination during residency and part I of the written examination
of the American Board of Orthopaedic Surgery upon completion of residency.
Practice-based competence may be the more appropriate measure of subspecialty
knowledge, especially for general orthopaedists.
Dr. David Thordarson was chosen as editor for this leadoff book in the
series. He chose appropriate fundamental topics to be included in a foot and
ankle rotation. Dr. Thordarson set his goals reasonably: "to cover
almost all aspects of orthopaedic foot and ankle surgery in an introductory
fashion to help residents prepare for the treatment of most foot and ankle
problems as well as for the orthopaedic in-service [sic] exam and the American
Board of Orthopaedic Surgery written exam."
There are two introductory chapters on anatomy and physical examination,
followed by twelve topics that are representative of foot and ankle problems
in adults. Most of the authors wisely chose to partner with residents,
fellows, and junior faculty. I say wisely because those of us who have had
many years of subspecialty practice have lost sight of the immediate nature of
the learning requirements during an orthopaedic residency. I asked several
current residents to read parts of the text as a reality check to see if the
book was connecting with residents as the series editors intended, and the
response I received was favorable.
The chapters are reasonably cohesive in that each maintains the overall
organization of a clear, simple text with ample illustrations. Minutiae are
avoided in most instances, and common problems (e.g., hallux valgus, plantar
fasciitis, posterior tibial tendon dysfunction, and ankle arthritis) are dealt
with in a concise summary fashion that gives the author's preferences in a
series of bullets. All the authors provide clear illustrations of current
surgical techniques (including a chapter on ankle and subtalar arthroscopy),
and an effort has been made to describe the use of advanced imaging studies in
the diagnosis of common foot problems.
The strengths of this book are also its weaknesses. The editor's choice of
which subjects to exclude must have been a difficult one. For example, there
is no discussion of pediatric foot and ankle problems because, in all
likelihood, that subject will be covered in an upcoming book on pediatric
orthopaedics. Yet, there is a section on fractures of the foot and ankle that,
in all likelihood, will be covered again in an upcoming book on trauma. How
does one adequately cover foot tumors, nondiabetic infections, amputations,
pain conditions, and psychogenic foot problems in such a brief text? A foot
and ankle rotation varies from four weeks to twelve weeks, and it seems
unreasonable for a resident to cover all fourteen chapters in some of the
shorter rotations. True, many of the programs with shorter rotations will have
two such rotations during the five years, but the rate at which new knowledge
is developed may mean that the information in a textbook will be outdated by
the time a junior resident becomes a chief resident.
In summary, I found Foot and Ankle to be a very easy read, with
good illustrations, bullet points, and tables to highlight the important
diagnostic and treatment items. The editor has provided a good leadoff hit for
this series that will cover all the rotation subjects in approved orthopaedic
residencies in the United States. This text belongs in the library of every
orthopaedic department, hospital, and medical center as well as in the
residents' on-call suite. One suggestion for a second edition would be for the
editor and authors to start with a teaching plan that includes
rotation-specific objectives and an acquaintance with the expectations of the
Residency Review Committee. Future incorporation of the six competencies
(something all teaching faculty are now struggling with) will become easier
with practice.