1. Lucas Bartlett D.O. 
2. Brandon Klein D.O., MBA
3. Peter White D.O., M.S.
4. Ravi Tata B.S.
5. Michael Linn M.D. 
6. Gus Katsigiorgis D.O.

ABSTRACT

Introduction
The Orthopedic In-Training Examination (OITE) is an annually conducted assessment established to assess the proficiency of orthopedic surgery residents. With the recent association of OITE performance and pass rates on the American Board of Orthopedic Surgery Part-I written examination, OITE preparation has become a greater focus within residency curricula.  

Objectives
We seek to provide an updated analysis of the orthopedic trauma section on the OITE, identifying trends and commonly tested topics.  

Methods
All trauma related questions on the OITE were analyzed between 2009-2013 and 2017-2020. Content subcategories, the number and types of references utilized, the incorporation of imaging modalities, and question taxonomy were recorded.  

Results
The trauma domain comprised 15.11% of all OITE questions over our entire analysis period. Injuries by anatomic location comprised roughly 70% of all OITE questions. General trauma management was the most commonly tested subcategory across both study periods. Simple recall knowledge (Taxonomy T1) comprised roughly 50% of all question types. Imaging modalities appeared on 43.85% of questions. The Journal Of Orthopedic Trauma, The Journal of Bone and Joint Surgery, The Journal of the American Academy of Orthopedic Surgeons, The Journal of Pediatric Orthopedics, and Clinical Orthopedic Related Research comprised 60% of articles referenced in all questions over our analysis period. There was an average publication lag of 7.61 years.  

Conclusion
Application of this data can aid residents in their preparation for the OITE.  

Keywords
ABOS, OITE, Trauma, Resident, Education

Introduction  
The Orthopedic In-Training Examination (OITE) has served as an established benchmark for assessing resident proficiency since its inception in 1963 [1]. Under the guise of the American Academy of Orthopedic Surgeons (AAOS), this annually conducted assessment is required for all orthopedic surgery residents in North America. Over the past several decades, the test has expanded to include approximately 275 questions, covering a targeted range of subspeciality topics or domains [2]. Over the past decade, multiple studies have attempted to define domain specific trends across test elements such as question taxonomy, content, and topic specific resident performance [3-11]. In light of recent literature indicating OITE performance as a predictor for success on the American Board of Orthopedic Surgery (ABOS) Part-I written examination, preparation for the OITE has become a larger focus within residency curricula and self-directed education [12, 13]. Additionally, updated analyses have been performed across several domains in an effort to define recent shifts from prior, outdated studies of the same nature [14, 15]. Principles of orthopedic trauma in particular, consistently receive a large focus on the OITE, yet available literature examining content from this domain fails to report beyond 2009 [4, 9, 16]. As sequential examinations stride to reflect contemporary changes in management principles and relevant, field specific research, having an accurate understanding of testable material is critical for residents and designing program curricula. Therefore, the purpose of this study is to provide an updated analysis of all trauma OITE questions between the years 2009-2020 with a focus on observing trends across question content, taxonomy, references and publication lag.  

Materials and Methods 
While our institution has recently published several updated analyses of certain OITE domains, each review was performed independently [14,15]. Regarding this analysis, methodology, in part, was designed in accordance with previous studies examining the trauma domain [4]. All trauma questions on OITE examinations between the years 2009-2013 (early), 2017-2020 (late) were identified and analyzed. Examinations between the years 2014-2016 were unable to be retrieved. Excluding the aforementioned years, data was intentionally recorded in two time periods to present comparative data. Questions from 2009-2013 were obtained from past examinations as distributed by the AAOS, while questions between 2017-2020 were obtained directly from the AAOS ‘ResStudy’ online portal [2]. Questions available through the ‘ResStudy’ portal were previously grouped by content domain from their respective examination year. However, questions from our earlier period lacked any domain designation. In this circumstance, questions were designated by two independent reviewers. Domain categorization was achieved through a combination of reviewing the AAOS ‘ResStudy” online platform, viewing prior AAOS assignments on individual score reports, and reviewer judgment when necessary [2]. Collectively, 60% (223/374) of all trauma questions were recorded in this manner. Any ambiguity required determination by a third independent reviewer.  

All selected questions were further delineated into specific subcategories in accordance with Lackey et al [4]. Two broad categories were established, principles of general trauma and injuries by anatomic location. Principles of general trauma were subcategorized into basic science, anatomy and surgical approaches, or general trauma management. Basic science included questions relating to bone and soft tissue physiology, biomaterials, or mechanical principles of orthopedic constructs while general trauma management consisted of questions related to critical care, open fracture management, damage control orthopedics (DCO), etc. Injury specific questions were assigned based on anatomic location. Subcategory determination was achieved by reviewing previously published studies of this manner, AAOS domain characterization on recent examinations, and author interpretation. Again, question assignment was performed independently by two reviewers with any discrepancies requiring agreement amongst a third independent reviewer.   

Question taxonomy was determined for all questions and was classified in accordance with Buckwalter et al [17] This taxonomic classification includes three types of questions: taxonomy 1 (T1) questions pertain to simple knowledge recall, taxonomy 2 (T2) questions require the examiner to make a diagnosis, interpret imaging, or identify an intraoperative problem, and taxonomy 3 (T3) questions pertain to management, decision-making, or treatment.  

The references for each question, as provided by the AAOS, were also recorded. The most commonly cited references as well as publication lag and mode were subsequently determined. Publication lag was defined as the difference between the reference publication year and the year that question appeared on the OITE. The inclusion of imaging or adjunctive media was also recorded, observing both the modality and frequency of appearance.  

Data including sub-topic, question taxonomy, number of references, most common references, lag year of references, and use of imaging modalities were analyzed and reported. Years prior to 2014 (early) and following 2016 (late) were considered their own group and compared within all analyses. Statistical analysis was performed using Excel (Microsoft, Redmond, WA). Continuous data between two groups were compared with independent 2 tailed T tests and 2-sample Z test for Proportions. Two-tailed P-values <0.05 were considered statistically significant. 

Results 
Trauma related questions comprised 15.11% (374/2475) of all OITE questions over our analysis period (Table 1). The mean (range) number of questions was 41.6 (26-51) while the weighted distribution ranged from 9.45%-18.6%. Trauma related questions comprised a lower percentage of total OITE questions in our later period, decreasing from 16.22% to 13.73%. The most commonly tested subcategories are shown in Supplementary A. The majority of questions were related to injuries by anatomic location, comprising 70.32% over our entire analysis period while the remaining questions were related to principles of general musculoskeletal trauma. Comparatively, injuries by anatomic location comprised a higher percentage of questions during our later period, increasing from 67.26% to 74.83%. Overall, general trauma management received the greatest emphasis (22.43%), followed by several subcategories within the injury by specific anatomic location section including femur (16.73%), elbow (11.43%), hip (8.37%), and acetabulum (8.37%).  The most commonly tested anatomy and surgical approaches section was the pelvis, comprising 4.94% of all questions over our entire analysis period. Similarly, the most commonly tested basic science section were questions regarding principles of plates and screws (4.56%).  

Questions involving general trauma management remained the most common question subtopic across time periods, although less frequently represented between 2017-2020 (p=0.48). With regards to tested injuries by anatomic location, femur was the most common across both periods, present on 1.7% more questions between 2017-2020 (p=0.94). Knee/extensor mechanism injuries received the largest increase in representation between periods, present on 5.6% more questions in more recent examination years (p=0.24). Additionally, injuries about the elbow, pelvis, and humerus all had increasing representation between periods, although statistically insignificant (p=0.69, p=0.71, p =0.36, respectively). Pelvic anatomy and surgical approaches remained the most commonly tested subtopic within this category across both periods (p=0.63). Collectively, the basic science section was less frequently tested during our later period, decreasing from 12.67% to 4.42% (p = 0.08). The majority of remaining subcategories either remained in similar proportions or decreased in representation between early and late periods, which can likely be attributed to the overall decreased number of questions per year in our late period. 

Adjunctive imaging modalities were utilized in 43.85% of all trauma questions (Table 2). Interpretations of radiographs were required in 41% of all questions, while 8% had advanced imaging, either MRI or CT. When observing only questions with imaging modalities present (n=164), radiographs comprised the overwhelming majority at 94% (n=155). Questions with more than one imaging modality were present on most examination years with a range of 1-6 questions. Comparing analysis periods, the presence of radiographs increased 15% between early and late periods (p = 0.07) while remaining modalities had an opposite trend. With regards to taxonomy, simple recall questions (T1) comprised 50% of all questions (Table 3). Decisions regarding management and appropriate next steps (T3) or establishing a diagnosis (T2) were present 35.03% and 23.26% of the time, respectively. The incorporation of more simple recall questions (T1) was observed between early and late periods, present in approximately 6.5% more questions between 2017-2020 (p= 0.01).  

There were a total 874 references cited from 105 sources (Table 4). The Journal Of Orthopedic Trauma (JOT), The Journal of Bone and Joint Surgery (JBJS), The Journal of the American Academy of Orthopedic Surgeons (JAAOS), The Journal of Pediatric Orthopedics (J Peds Ortho), and Clinical Orthopedic Related Research (CORR) comprised approximately 60% of all references over our entire analysis period. The Journal of Orthopedic Trauma was the most commonly referenced journal in both our early and late period, 21.98% and 25.28%, respectively. Several textbooks, when combining multiple editions, were notably referenced and should be mentioned. The Orthopedic Knowledge Update series comprised 3.32% of all references, while Skeletal Trauma and Rockwood and Greens Fractures in Adults made up 2.52% and 2.29% respectively. However, a subjective trend away from incorporating textbooks during our later period was observed. There was an average publication lag of 7.61 years over our entire analysis period with 26.8% of citations published within 2 years of respective test dates and 74.6% of citations published within 10 years of respective test dates (Table 5). Lag time remained relatively consistent between our analysis groups (p=0.80). A higher percentage of references in our later period were published within 2 years of test date, 24.52% versus 29.05%, although statistically insignificant. The average lag time mode for our early period was 2.2 years, while the average lag time mode in our late period was 2.0 years. There was an average of 2.33 publications per question over the span of 2009-2013, which slightly increased to 2.40 publications per year in our later group (p=0.69).  

Discussion 
Our study provides an updated analysis of the trauma domain with the intended purpose of identifying relevant trends across multiple aspects of the OITE. To our knowledge, the most recent series of this nature were performed over a decade ago, examining years up until 2009 [4, 9, 16]. Upon our analysis, 374 trauma questions were analyzed from a total of 2,475 questions. Overall, this section remained relatively consistent with the intended weighted distribution defined by the 2020 AAOS Technical Report, marking trauma as the most commonly represented domain [2]. While the weight of the trauma section decreased from 16.22% to 13.73% over our two study periods, which may suggest it is becoming less prominent, the trauma domain continues to be one of the most frequently encountered OITE topics and is a core foundation of orthopedic practice.  

The number of questions and breadth of orthopedic trauma made it difficult to list every injury separately as observed in other studies of this nature [15, 18, 19]. Questions were categorized in accordance with Lackey et al, for ease of cross study comparison and overall feasibility [4]. It should also be noted that “fractures” or “injuries” extends into multiple disciplines of orthopedics and this study is not entirely inclusive with encountering questions that incorporate fractures. For example, previous literature has suggested that fractures constitute a large portion of the hand and foot and ankle domain [20, 21]. Our decision to exclude these questions in our analysis was based on the notion that test writers typically refer to their own subspecialty literature during question writing as demonstrated in previously reported analyses of this nature [19, 22]. 

As we compared the frequency of subcategory testing across our analysis periods, questions related to injuries by anatomic location continue to comprise the majority of trauma related questions and should be a primary area of focus during test preparation. Questions regarding femur pathology, which in our study spanned from the subtrochanteric region to distal femur, continue to be highly tested, serving as the most commonly tested anatomic site overall. Elbow pathology appears to be gaining more prominence within this section, serving as the second most commonly tested anatomic site overall with increasing representation between early and late periods. Questions within this subcategory were predominantly related to pediatric elbow pathology including supracondylar fractures and medial or lateral epicondyle fractures. Traditionally highly tested anatomic sites including the pelvis, acetabulum, and hip also comprised the top five most common sites overall, with both hip and pelvis pathology demonstrating increased representation during our later period. Knee/extensor mechanism injuries, interestingly, demonstrated the largest increase between early and late periods and should be an additional area of focus for preparation. Commonly encountered question scenarios include patella fractures, quadriceps/patellar tendon pathology, multiligamentous knee injuries/dislocations, or traumatic arthrotomies. Questions categorized under general trauma principles were predominantly composed of general trauma management directed questions and typically pertained to emergency room management, DCO, or open fracture management. Basic science principles had poor representation in our later period, and may continue to be less favored in upcoming examination years. Pelvic anatomy and surgical approaches were favored compared to upper and lower extremity directed questions and should be prepared for accordingly.  

Roughly half the questions were taxonomic grade T1, which may be attributed to the incorporation of basic science or anatomy based questions, which often require simple recall from specific literature sources. The interpretation of radiographs continues to be an important element of test taking with increased incorporation observed in more recent years. Our analysis discovered that roughly 60% of all references were derived from one of five journals: JOT, JBJS, JAAOS, J Peds Ortho, and CORR. The Journal of Orthopedic Trauma was the most cited publication across both periods, which demonstrates the consistency in which question writers refer to their own subspeciality literature. Interestingly, the Journal of Pediatric Orthopedics was referenced more frequently in our later period, increasing from 2.53% to 11.94%, which correlates with the increasing representation of pediatric elbow pathology observed. A subjective trend towards incorporating more recent literature was noted. For example, Orthopedic Knowledge Update: Trauma 3 was last cited in 2010, while Orthopedic Knowledge Update: Trauma 4 was cited 15 times over the subsequent 3 years. In addition we found that roughly one quarter of all references over our entire analysis period were published within two years of their appearance on the OITE. The higher percentage of journals referenced within 2 years of publication observed in our later group (24.52% versus 29.05%), may further indicate that test makers are trying to incorporate more recent literature. However, the average lag time across our entire analysis period of 7.61 years is consistent with prior studies examining additional domains [14-16, 20]. 

Aggregate data within our analysis period (2009-2013, 2017-2020) was also compared with a previous analysis of the trauma domain. Lackey et al, examined the trauma section on the OITE from 2005-2009 [4].  The trauma domain comprised 18.8% of all OITE questions over their study period. Imaging modalities were present on 28% of all questions with radiographs comprising 83.3%. Roughly 60% of questions were T1. In regards to subcategory analysis, questions on general principles accounted for 35.9% of questions while specific injuries by anatomic location comprised the remaining 64.2%. Anatomy and surgical approaches questions comprised 13.4% of questions while basic science questions were present in 14.2% of the time. General trauma management comprised only 10.2% of all questions, while femur, hip, and ankle were the most commonly tested injuries by location. The Journal of Orthopedic Trauma was most commonly referenced.  

Upon cross study comparison, the weighted distribution of the trauma section appears to be decreasing over the past 15 years. The proportion of radiographs to other imaging modalities remained relatively consistent when compared to our analysis, although imaging modalities were present more frequently within our study period. Collectively, simple recall questions appear to be present on a higher percentage of questions within their analyses, compared to 50% in our study, which may suggest an overall trend towards the inclusion of more complex questions. However it should be noted that T1 questions demonstrated a 6.5% increase in our later period and differences between studies may be related to the errant nature of subjective taxonomic assignment. General trauma management questions had more than double the weighted distribution in our analysis and remained the most commonly tested subgroup, however general trauma principles collectively appear to be decreasing in representation comparatively. 

This study has several limitations. Question categorization is not absolute and to some degree is left to the interpretation of the reviewer. Trauma related questions extend to multiple domains of the OITE with prior literature demonstrating that “fractures” or “trauma” comprise a substantial portion of the hand, foot and ankle, and pediatric topics [20, 21, 23]. Domain overlap may be difficult to discern in some instances and errors in question categorization may be present. Secondly, taxonomic classification is also a subjective assessment and may be subject to variability. Resident performance was not recorded in our study. Score percentages were not accessible between the years 2009-2013 and resident performance was excluded entirely for lack of comparative data. Karam et al compared the percentile scores of second year orthopedic surgery residents on the trauma section of the OITE and found that residents who took a trauma preparation course and/or had a trauma rotation prior to examination did significantly better than those who did not [24]. Comparing resident performance against trends in other domain specific test characteristics may be an additional adjuvant in test preparation and should be addressed in future studies of this nature.  

Conclusion 
Observing the progression of question content and test-making strategies may aid residents in their strategic preparation for the OITE. Our analysis establishes the pertinence of particular trauma-related topics which residents may utilize to triage study focus. Lastly, with the emergence of online educational resources and curricula, analyses such as this may permit residency programs to create a more integrative, tailored approach to training.  

Figure 1 | Figure 2 | Figure 3 | Figure 4 | Figure 5 | Figure 6 | Figure 7 | Figure 8 | Figure 9

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