Examination Entry Criteria

GENERAL
Post Basic Trauma and Orthopaedic Examination and Training
All candidates shall provide evidence of completion of the relevant Basic Trauma and Orthopaedic examination and training certificate for their country of origin and shall have been in a Consultant Orthopaedic Foot and Ankle post or equivalent for at least 5 years.

Logbook
A complete logbook of surgical cases shall be required preferably electronically for ratification by the examination board before proceeding to the examination.

EFAS CRITERIA
It has been agreed that the following additional EFAS criteria are required.
Letter of Recommendation
A letter of recommendation and confirmation that the candidate has fulfilled the entry requirements is mandatory from the department head. One or two further references are
desirable.

Meetings
Evidence of attendance at 3 EFAS meetings. These would include Basic Instructional Courses, Cadaver Courses or the Annual Meeting/Advanced Instructional Course. As the examination shall precede the latter subsequent attendance at this meeting may be considered appropriate in occasional circumstances.

Publications
Evidence of at least two international publications in appropriate Journals on Foot and Ankle Surgical topics shall be required. Preference shall be given to those publishing in the Journal of the European Foot and Ankle Society.

Fellowships
Evidence of appropriate Fellowship training in a Foot and Ankle Surgery Centre of Excellence is not obligatory but desirable. A list of Centres throughout Europe has been collected but consideration may be given to other International Fellowships. The minimum time period is three months but this may include training for shorter periods in several centres.

Curriculum

Introduction

The purpose of this curriculum is to provide a basis for the certification of young trainee trauma and orthopaedic surgeons specialising in foot and ankle management and surgery. It is clear that there may be a case for separating trauma and elective foot and ankle surgery but they are quite significantly intertwined and although the emphasis may be different in different countries it has been deemed appropriate to provide this certification across the speciality. A similar case may be made about separating paediatric conditions eg. CTEV from adult conditions but, again, there is a continuum in to adult life and a basic understanding is invaluable to the adult foot and ankle surgeon treating their subsequent effects.

All the requirements for the CV are indicated below the application form. Be sure you have read all the information before applying.

Certification's application

Curriculum requirements

General Principles

The satisfactory practice of Trauma and Orthopaedic Foot and Ankle Surgery involves taking an adequate history, performing a thorough examination (evaluation), requesting appropriate confirmatory diagnostic tests and thereafter providing a comprehensive explanation of the conservative and surgical options available to the patient.
General knowledge may be obtained from relevant Books, Journals and Publications but it is accepted that some will be country dependent, and some generally available.
In addition, it has been suggested that further specific training in a Centre of Excellence or Fellowship Centre with a clinical supervisor would be complimentary to this curriculum with a minimum of 50 CME points over two years in foot and ankle surgery and a minimum of 2 peer reviewed foot and ankle papers in international journals. This is discussed elsewhere.
Evidence that the applicant has fulfilled these criteria shall be required and confirmation that they may proceed shall be determined by the examination board on an individual basis as previously outlined.
The following is a guide to the topics, which are likely to be encountered but is not intended to be exhaustive and is subject to change. It covers Basic Science applied to the Ankle and Foot, Paediatric, Adult Orthopaedic and Traumatic Foot and Ankle Surgery.

Basic Science

• Anatomy

Clinical and functional anatomy with pathological and operative relevance to the foot and ankle, anatomy of the nervous and vascular systems in the foot and ankle including surface markings, surgical approaches to the foot and ankle, bones and articulations, ligamentous structures (ankle, hindfoot, midfoot, forefoot, plantar fascial and MTP anatomy, tendon anatomy and muscle compartments in the foot.

• Biomechanics/Bioengineering/Prosthetics and Orthotics

Function of the lower limb and foot in gait including kinematics and gait analysis, ankle and subtalar joint biomechanics, plantar fascial mechanisms, tendon function, biomaterials, implant design and implant failure, tribology of natural and artificial joints, principles of design of prosthetics/orthotics, prescription and fitting of standard prostheses, principles of orthotic bracing for control of disease, deformity and instability, orthoses and footwear.

• Research and Audit

Design and performance of clinical trials, data analysis and statistics (principles and applications), principles of epidemiology and statistics and audit.

• Medical Ethics

Duties of care, informed consent and medical negligence.

Pathology

• General

Osteoarthritis (primary and secondary), osteoporosis/osteopaenia, metabolic bone disease, rheumatoid arthritis and other poly-arthropathy, inherited musculoskeletal disorders, neuromuscular disorders (inherited and acquired) and osteochondral lesions.

• Neuropathy/Neurological disorders

Diabetic foot, Charcot neuro-arthropathy, Morton’s neuroma, Nerve entrapment eg tarsal tunnel syndrome. neurological foot deformity, neuropathic joint and skin changes.

• Tumours

Knowledge of the presentation, radiological and pathological features, treatment and outcome for common benign and malignant tumours in the foot and ankle. Knowledge of the presenting features, management and outcome of soft tissue lesions including sarcomas.

• Specific

o Ankle and Hindfoot
Hindfoot pain, ankle instability, heel pain, degenerative disease of the ankle, rheumatoid arthritis, osteochondral lesions of the talus.
o Forefoot Disorders
Hallux valgus, hallux rigidus, lesser toe deformities, metatarsalgia, inflammatory arthropathy.
o Complex Foot and Ankle Deformity
Flatfoot deformity (mobile and rigid, childhood and adult acquired), cavus and cavo- varus deformity, residual congenital foot deformity.

Investigation

Relevant blood tests, musculoskeletal imaging: x-ray, contrast studies (arthrography), CT, MRI, ultrasound, radioisotope studies, effects of radiation, bone densitometry, electrophysiological investigation.

• Radiographs

Standard foot and ankle radiographs, additional foot and ankle radiographs.

• CT, MRI, Ultrasound and Nuclear Medicine

Knowledge of the role of these ancillary investigations in certain specific conditions eg. Infection, tumour, tibialis posterior dysfunction, osteonecrosis.

• Electrophysiology

Relevance to foot and ankle disorders.

Management

Non-operative

Prosthetics and orthotics, footwear, physiotherapy, medical podiatry.

Operative

• General

A detailed knowledge of closed and operative methods for the management of fractures and dislocations of the ankle, hindfoot, midfoot and forefoot.
A detailed knowledge of common reconstructive surgical procedures for foot deformity for example hallux valgus, lesser toe deformity, acquired adult flat foot include arthroplasty, arthrodesis, osteotomy and soft tissue reconstruction
Knowledge of common amputations in the foot and ankle
Knowledge of common reconstructive surgical procedures for degenerative and inflammatory disorders of the ankle and foot including arthrodesis, arthroplasty and excision arthroplasty and interventions in the first ray both proximal and distal for the management of hallux valgus and rigidus

• Operative Topics

Tourniquets (thigh and calf), design of theatres, skin preparation, anaesthesia (principles and practice of local and regional anaesthesia and principles of general anaesthesia).

• Infection, VTE and Pain

Infections of bone, joint, soft tissue, including TB, and their prophylaxis, sterilisation, VTE (prophylaxis and bleeding risk), behavioural dysfunction and somatisation, AIDS and surgery in high-risk cases, pain and pain relief, complex regional pain syndromes eg RSD, compartment syndrome in the foot and ankle.

Trauma

• Wound Management

It is considered that a detailed knowledge of plastic surgical techniques is not required but it is appropriate to have a basic understanding of the following:
Free flap, full thickness skin graft, muscle flap, nerve repair, pedicle flap, transpositional flap, split skin graft, wound closure (delayed primary or secondary), wound debridement, removal of foreign body from skin or subcutaneous tissue.

• Tibia and Fibula

It is considered that a detailed knowledge of the following surgical techniques is not required by some practising orthopaedic foot and ankle surgeons but it is appropriate to have a basic understanding of the following:
Diaphyseal tibial fractures external fixation (including frame), diaphyseal tibial fractures intramedullary nailing, diaphyseal tibial fractures MUA and POP, tibial shaft plating, tibial non-union, tibial non-union circular frame management, tibial non-union intramedullary nailing +/- bone graft.

• Ankle

Ankle fracture/dislocation classification (Lauge-Hansen, Weber, AO), ankle fracture/dislocation MUA and POP, ankle fracture/dislocation ORIF, Pilon fracture, Pilon fracture ORIF, Pilon fracture with circular frame, Tendo Achilles (Percutaneous, open).

• Foot

Amputation toe/ ray for trauma, calcaneal fracture (ORIF, external fixation, arthroscopically assisted, minimally invasive), talar fracture (ORIF), metatarsal fracture ORIF eg Jones fracture, phalangeal fracture MUA +/- K wire +/- ORIF, talar, subtalar or midtarsal fracture/dislocation, talar, subtalar or midtarsal fracture/dislocation MUA +/- POP +/- K wires, talar, subtalar or midtarsal fracture/dislocation ORIF

Elective

• Elective – Nonspecific

Aspiration/injection joint, benign tumour excision, biopsy bone (needle, open), bursa excision, ganglion excision, bone cyst curettage +/- bone graft, malignant tumour excision.

• Ankle

Supramalleolar osteotomy, arthrodesis ankle (open or arthroscopic), arthroplasty ankle, arthroscopy ankle diagnostic (anterior and posterior approaches), arthroscopy ankle therapeutic eg talar osteochondral lesions, arthrotomy ankle, ankle instability including medial and lateral ligament reconstruction and repair, subtalar arthrodesis (open or arthroscopic), triple arthrodesis (open or arthroscopic), Choparts arthrodesis, decompression or reconstruction of tendons at the ankle eg. Tibialis posterior dysfunction (FDL transfer, Cobb reconstruction and allied procedures), tendon transfers, dislocation of the peroneal tendons – relocation, Tendo Achilles surgery including late repair, decompression and lengthening.

• Foot

Amputation toe /ray, Calcaneal osteotomy, CTEV correction, Ponseti management, spring ligament reconstruction, plantar fascial reconstruction, repair or release, midfoot arthrodesis including medial column shortening and lateral column lengthening, wedge tarsectomy, first metatarsal osteotomy – proximal (including Lapidus), distal, Scarf, proximal phalangeal osteotomy (Akin), first MTPJ cheilectomy, first MTPJ arthrodesis, first MTPJ excision arthroplasty, first MTPJ soft tissue correction, lesser metatarsal osteotomy, elongation or shortening of metatarsals, lesser toe arthrodesis eg hammer toe, curly toe, clawed toe, lesser toe excision part/all phalanx, lesser toe tenotomy, fifth toe soft tissue correction, bunionette surgery, surgical management Morton’s neuroma, surgical management Freiberg’s disease, forefoot reconstruction and arthroplasty, tendon decompression or repair, tendon transfers, minimally invasive surgery in the foot and ankle.
Ingrowing toenail surgery. It is accepted that this condition may not be treated by Orthopaedic Foot and Ankle Surgeons throughout Europe.