The Orthopaedic In-Training Examination (OITE), produced by the American Academy of Orthopaedic Surgeons, was first administered in 1963. It was the first surgical subspecialty examination of its kind to be administered to resident trainees. The inaugural OITE consisted of 150 questions derived from the American Board of Orthopaedic Surgery (ABOS) examination1.
The number of questions on the OITE and the number of examinees taking the test have increased substantially during subsequent test administrations. The most recent examination (2008) consisted of 275 questions that were administered to 4137 examinees. The current test is divided into twelve domains: sports medicine, foot and ankle, hand, hip and reconstruction, medically related issues, orthopaedic diseases, basic science and tumors, pediatric orthopaedics, rehabilitation, shoulder and elbow, spine, and musculoskeletal trauma.
After the OITE examination, the score reports are returned to individual examinees, along with a list of preferred responses for each question and associated literature or textbook references. As a result, the OITE serves as an important educational tool identifying areas of weakness and future study for individual examinees.
Recently, Frassica et al.2 and Marker et al.3 published analyses of the OITE pathology and hand sections. The information derived from these studies enables trainees to study more comprehensively, facilitating the development of a core orthopaedic knowledge base. Additionally, faculty may use this information to direct journal club topics and didactic lectures and to improve their educational curriculum.
To our knowledge, no analysis of the sports medicine questions on the OITE has been published. The purpose of this study was to systematically examine the OITE sports medicine questions, along with the associated answers and recommended reading lists, during a five-year period. This analysis produced a list of commonly tested topics and provides an educational resource that residents and attending surgeons may use to aid subsequent study and the development of individual residency educational curricula.
We analyzed the sports medicine domain questions on the OITE during a five-year period (2004 to 2008). The program director's report was used to calculate the total number of questions. Questions discarded by the examiners prior to returning the score reports were excluded.
The sports medicine questions were quantified and recorded. The topics addressed by each question, the treatment modalities, and the subsequent steps in management, such as additional imaging, if applicable, were identified and tallied. Imaging modalities, such as radiographs, magnetic resonance imaging, or a clinical photograph associated with a question, were described.
Additionally, the questions were further categorized with use of a taxonomic classification described by Buckwalter et al.4 and Frassica et al.2. Simple-recall questions (type 1) involve recollection of facts without specific cognitive problem-solving. Diagnosis-type questions (type 2) require the examinee to establish a diagnosis from the clinical history and/or radiographic studies provided in the question stem. Evaluation or decision-making questions (type 3) demand the highest order of cognitive function from the examinee. These questions ask the examinee to establish a diagnosis and subsequent treatment plan from the information provided in the question stem.
Finally, the recommended reading list for each question was reviewed. First, the references were subcategorized by source (journal article or textbook). All scientific articles, case reports, and review articles, including instructional course lectures, were included in the "journal" category. The number of individual references for each journal or textbook and the associated OITE test year were recorded. For the primary literature sources, the publication year was recorded and compared with the OITE test administration year. Additional analysis was performed to identify the most recent articles from The Journal of Bone and Joint Surgery (JBJS) (American Volume) and the classification of these articles within The Journal.
Analysis of the OITE tests administered from 2004 to 2008 revealed that between twenty-one and twenty-two questions were in the sports domain each year, accounting for approximately 7.9% (106) of all 1349 questions tested (Table I). The anterior cruciate ligament was the most commonly tested topic. Over the five-year study period, concepts pertaining to the anterior cruciate ligament were tested by twenty-five different questions, accounting for 24% (twenty-five) of all 106 sports questions tested (Table II). The second most common topic tested was "foot injuries in the athlete," which represented 7% (seven) of all 106 questions in the sports domain (Table II).
Further analysis revealed that the anterior cruciate ligament questions addressed several aspects of patient care: risk factors for injury, diagnosis from magnetic resonance imaging, identifying associated injuries such as the Segond fracture, indications for and types of revision surgical procedures, and postoperative rehabilitation. Questions regarding "foot injuries in the athlete" focused on metatarsal stress fractures, treatment of Jones fractures in the athlete, plantar fasciitis, surgical treatment of Achilles tendon rupture, and physical examination findings related to peroneal tendon subluxation. Sixteen other topics were addressed by more than one question from 2004 to 2008. These topics, along with topics addressed by a single question, are listed in Table II.
Treatment modalities, such as ligament reconstruction or physical therapy, were addressed by 48% (fifty-one) of the 106 OITE questions in the sports domain (Table III). For example, questions addressed the need for physical therapy after an acute tear of the anterior cruciate ligament prior to surgery, tensile strength for different anterior cruciate ligament grafts, proper tensioning of the anterior cruciate ligament graft, and postoperative complications, including hematoma, after anterior cruciate ligament surgery. Table III lists the other treatment modalities tested.
Imaging modalities were included in 20% (twenty-one) of the 106 OITE sports questions. Radiographs (53%, eleven of twenty-one questions) and magnetic resonance imaging (43%, nine) were the two most common imaging modalities tested.
Taxonomy analysis demonstrated that simple-recall questions (type 1) were the most common, representing 67% (seventy-one) of all 106 sports medicine questions. Diagnosis questions (type 2) were the least common, accounting for 8% (eight) of 106 questions, while 25% (twenty-seven) of the questions required a diagnosis and subsequent treatment plan (type 3). These results are presented in Table IV.
Analysis of the recommended reading list for each OITE question revealed that 75.3% (165 of 219 total references reported) were from journals. Textbooks accounted for 24.7% (fifty-four) of the 219 references. The American Journal of Sports Medicine was the most common journal cited, accounting for 33% (fifty-four) of 165 references. Orthopaedic Knowledge Update: Sports Medicine (second or third edition) was the most common textbook cited, accounting for 48% (twenty-six) of fifty-four references. Table V lists all of the journals and textbooks referenced.
Analysis of the reference publication dates showed that 59% (ninety-eight) of the 165 primary literature sources cited were published within five years of the OITE test administration; 22% (thirty-seven) were published five to ten years prior to test administration; and 18% (thirty) of the references were published more than ten years prior to the date of the test. A closer review of the most recent journal articles noted that 10% of all articles referenced were within one year of their respective OITE administration (Table VI). Five of the twelve articles from JBJS were published within three years of their respective inclusion in the OITE examination, including two articles from 2005 addressed in the 2006 examination.
The JBJS references were analyzed in greater detail as well. Six of the twelve references originated from the "Scientific Articles" section. Other types of JBJS articles that were referenced included "Case Reports," "The Orthopaedic Forum," "Current Concepts Review," and "Selected Instructional Course Lectures." It is of note that three articles were published prior to 1996, when articles were not divided into subcategories within The Journal. We grouped two of these articles with the "Scientific Articles" section after review of the published article; one article from the 2004 examination was classified as a "Case Report."
Since its inception in 1963, the OITE has served as an important educational tool for resident trainees and faculty of individual residency programs. Examinees have used the test to identify individual knowledge deficiencies and direct areas of future study. Program directors have used the results of the examination to identify and subsequently improve weaknesses in the educational curriculum at their respective programs.
Recently, Frassica et al.2 and Marker et al.3 completed analyses of the OITE pathology and hand questions, respectively, for the 2002 to 2006 test administrations. Both studies developed a list of commonly tested topics that would allow trainees to study more comprehensively as they prepared for future examinations. Additionally, the study performed by Marker et al.3 examined the relationship between the hand or wrist topics most commonly tested on the OITE and the current primary literature. Their study revealed that there was a correlation between the topics tested on the hand portion of the OITE examination and the hand surgery-related topics published in the following journals: The Journal of Bone and Joint Surgery (American Volume), The Journal of Bone and Joint Surgery (British Volume), and Clinical Orthopaedics and Related Research.
We evaluated the sports medicine OITE questions from 2004 to 2008, providing a list of commonly tested sports topics, treatment modalities, and imaging modalities. These lists may be used by examinees to study for subsequent tests in a more systematic and comprehensive way. Additionally, the generated list of topics may be used by examinees to facilitate the development of a core knowledge base through dedicated reading related to each topic.
The topics may also be analyzed by program directors and faculty to determine if specific educational topics are adequately addressed by individual training programs during didactic sessions. It is of note that magnetic resonance imaging was involved in 42% of the sports medicine questions testing interpretation of imaging modalities. Faculty may consider incorporating specific teaching sessions dedicated to magnetic resonance imaging interpretation into their education curriculum.
Although the study performed by Marker et al.3 established a correlation between the topics tested in the hand domain of the OITE and topics reviewed in the current primary literature, they did not examine when the references in the recommended reading list provided for each question were published in relationship to the OITE test administration. Our study showed that >75% of the references provided were from primary literature sources. Of these references, almost 60% were published within five years of the OITE test administration. The American Journal of Sports Medicine, Arthroscopy, and The Journal of Bone and Joint Surgery (American Volume) were the most common journals referenced, establishing the importance of reviewing the subspecialty journals in addition to the core orthopaedic journals when learning about sports medicine-specific topics.
The results of the present study suggest the importance of regularly reviewing the current subspecialty literature as well as the current primary literature. A substantial number of orthopaedic residency programs hold journal clubs, with 99% (147) of 149 responding program directors reporting regular participation5. Currently, a regularly scheduled subspecialty-specific journal club is a requirement for maintaining an accredited sports medicine fellowship. Journal clubs are a dedicated venue for systematically reviewing the current primary literature on a regular basis. Given the results of this study, journal clubs with a subspecialty focus may improve residency education.
Limitations of this study include our method of reviewing only questions that were included in the sports medicine domain, as classified by the test makers. There may be questions addressing sports medicine topics, such as ankle sprains or cartilage regeneration, that were included in other domains, such as foot and ankle or basic science, respectively. Another limitation is the descriptive nature of the study. Since there was no comparison group, hypothesis testing was not possible. The results of this study and the conclusions drawn should be interpreted in light of these limitations.
Trainees may use the information provided by this study to ensure that they are not neglecting important topics of study in the course of their development as practicing orthopaedic surgeons. Program directors and faculty may use this information to help to develop and refine their current residency curriculum. More effective education should result in better practitioners and raise the standard of care delivered to all of our patients.
Mankin
HJ. The Orthopaedic In-Training Examination (OITE). Clin Orthop Relat Res.
1971;75:108-16.[PubMed][CrossRef]
Frassica
FJ;
Papp
D;
McCarthy
E;
Weber
K. Analysis of the pathology section of the OITE will aid in trainee preparation. Clin Orthop Relat Res.
2008;466:1323-8.[PubMed][CrossRef]
Marker
DR;
Mont
MA;
McGrath
MS;
Frassica
FJ;
LaPorte
DM. Current hand surgery literature as an educational tool for the Orthopaedic In-Training Examination. J Bone Joint Surg Am.
2009;91:236-40.[PubMed][CrossRef]
Buckwalter
JA;
Schumacher
R;
Albright
JP;
Cooper
RR. Use of an educational taxonomy for evaluation of cognitive performance. J Med Educ.
1981;56:115-21.[PubMed]
Greene
WB. The role of journal clubs in orthopaedic surgery residency programs. Clin Orthop Relat Res.
2000;373:304-10.[PubMed] [CrossRef]
Arendt
EA, . Orthopaedic knowledge update. Sports medicine 2. Rosemont, IL: American Academy of Orthopaedic Surgeons; 1999.
Garrick
JG, . Orthopaedic knowledge update. Sports medicine 3. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2004.
DeLee
JC;
Drez
D
Jr, . DeLee and Drez's orthopaedic sports medicine: principles and practice. 2nd ed. Philadelphia: Saunders; 2003.
Miller
MD;
Cooper
DE;
Warner
JJP. Review of sports medicine and arthroscopy. Philadelphia: Saunders; 1995.
Koval
KJ, . Orthopaedic knowledge update 7. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2002.
Vaccaro
AR, . Orthopaedic knowledge update 8: home study syllabus. Rosemont, IL: American Academy of Orthopaedic Surgeons; 2005.