Influence of Training Background on Elbow Arthroplasty Case Numbers: An Analysis of the American Board of Orthopaedic Surgery Part II Oral Examination Case List Database.

INTRODUCTION: This study aimed to evaluate the influence of training background on the frequency and indications of elbow arthroplasty performed by early-career surgeons. METHODS: A review of the American Board of Orthopaedic Surgery Part II Oral Examination Case List database from 2010 to 2021 was completed. The number of cases performed by surgeons from each individual training background were calculated and compared with the total number of surgeons who completed each fellowship during the study period. RESULTS: Hand surgeons performed the most elbow arthroplasty cases (132, 44%), but a higher percentage of shoulder/elbow surgeons performed elbow arthroplasty in comparison (15% vs. 7%). The mean number of TEA cases performed by shoulder/elbow surgeons was significantly higher than in other subspecialties (P < 0.01). However, when comparing only surgeons who performed elbow arthroplasty during the board collection period, there was no significant difference between training backgrounds (P = 0.20). DISCUSSION: While hand surgeons performed the most elbow arthroplasty cases, a higher percentage of shoulder/elbow surgeons performed elbow arthroplasty during the study period. The high prevalence of distal humerus fracture as an indication for arthroplasty reflected a shift in indications and was not related to training background.

Ankle fracture surgery performed by orthopaedic residents without supervision has comparable outcomes to surgery performed by fellowship trained orthopaedic surgeons.

BACKGROUND: Unstable fractures often necessitate open reduction and internal fixation (ORIF), which generally yield favourable outcomes. However, the impact of surgical trainee autonomy on healthcare quality in these procedures remains uncertain. We hypothesized that surgery performed solely by residents, without supervision or participation of an attending surgeon, can provide similar outcomes to surgery performed by trauma or foot and ankle fellowship-trained orthopaedic surgeons. METHODS: A single-center cohort of an academic level-1 trauma center was retrospectively reviewed for all ankle ORIF between 2015 and 2019. Data were compared between surgery performed solely by post-graduate-year 4 to 6 residents, and surgery performed by trauma or foot and ankle fellowship-trained surgeons. Demographics, surgical parameters, preoperative and postoperative radiographs, and primary (mortality, complications, and revision surgery) and secondary outcome variables were collected and analyzed. Univariate analysis was performed to evaluate outcomes. RESULTS: A total of 460 ankle fractures were included in the study. Nonoperative cases and cases operated by senior orthopaedic surgeons who are not trauma or foot and ankle fellowship-trained orthopaedic surgeons were excluded. The average follow-up time was 58.4 months (SD ± 12.5). Univariate analysis of outcomes demonstrated no significant difference between residents and attendings in complications and reoperations rate (p = 0.690, p = 0.388). Sub-analysis by fracture pattern (Lauge-Hansen classification) and the number of malleoli involved and fixated demonstrated similar outcomes. surgery time was significantly longer in the resident group (p < 0.001). CONCLUSION: The current study demonstrates that ankle fracture surgery can be performed by trained orthopaedic surgery residents, with similar results and complication rates as surgery performed by fellowship-trained attendings. These findings provide valuable insights into surgical autonomy in residency and its role in modern clinical training and surgical education. LEVEL OF EVIDENCE: Level III - retrospective cohort study.

Patellar Fracture Surgery Performed Autonomously by Residents, Yields Similar Short-Term Outcomes to Surgery Performed by Fellowship-Trained Surgeons.

BACKGROUND: Open reduction and internal fixation are the gold-standard treatment for displaced patellar fractures. The current literature remains inconclusive on the relationship between resident participation in the operating room and optimal patient outcomes. We hypothesize that surgeries performed solely by residents, without attending supervision, can provide similar outcomes to those performed by fellowship-trained orthopedic surgeons, providing new insights into the relationship between resident autonomy and surgical outcomes in the field of orthopedic trauma. METHODS: A tertiary trauma center cohort was retrospectively reviewed for all surgically treated patellar fractures between 2015 and 2020. The cohort was divided into 2 groups: patients operated by residents and patients operated by orthopedic trauma specialists. Demographics, surgical parameters, and radiographs were compared between the groups to evaluate complications and reoperation rates, radiographic outcomes (such as hardware failure, or loss of reduction), and clinical outcomes (including residual pain, painful hardware, decreased range of motion, and infections). RESULTS: A total of 129 patellar fractures were included in the study. Demographics and ASA were similar between the groups. There were no significant differences in complications (p = 0.900) or reoperation rates (p = 0.817), with an average follow-up time of 8 months (SD ± 5.3). Residents had significantly longer surgery duration (p =0.002). However, the overall length of stay was shorter in the resident group (p < 0.001). CONCLUSION: The study shows patellar fracture surgery performed by adequately trained residents can provide similar outcomes to those performed by fellowship-trained orthopaedic trauma surgeons. These findings highlight the significance of surgical autonomy in residency and its role in contemporary surgical education.

#lowbackpain on TikTok: A New Frontier for Orthopaedic Medical Education.

INTRODUCTION: Low back pain has become a substantial health problem in all developed countries. Many healthcare professionals and content creators have begun sharing their treatment methods and opinions through social media, especially the video-based platform TikTok. TikTok has been downloaded more than 2.6 billion times with over a billion daily users. Its influence on public health makes it imperative that information be accurate and safe. This study aims to analyze TikTok's most popular content on lower back pain and how orthopaedic surgeons contribute on this growing platform. OBJECTIVES: To analyze TikTok's most popular content on lower back pain and how orthopaedic surgeons are and can contribute on this growing platform. METHODS: A TikTok search conducted on April 22, 2023, using the terms '#lowerbackpain'and '#lowbackpainrelief,' resulted in numerous videos, 100 of which met inclusion criteria. Videos were included if they were related to the content, had more than 1000 views, were in English, and were not duplicates. Video characteristics were recorded and evaluated for quality by two reviewers using DISCERN. A two-sample t-test was used to assess differences. RESULTS: Overall, the top videos on lower back pain had an average of 2,061,396 views, with a mean DISCERN score of 34. The mean total DISCERN score was 36 and 34 for physicians and nonphysicians, respectively, while the video by the orthopaedic surgeon (n = 1) scored 31. The most recommended treatments included at-home exercises (n = 75) and visiting a chiropractor (n = 4). CONCLUSION: We find that the information presented by nonphysicians offered quick, at-home fixes to medical problems without offering any research or proven data to support their claims. We cannot overlook Tiktok's immense influence in the realm of orthopaedic health as it has become a sphere of information dissemination and education. Thus, we suggest that there is not necessarily a need for a greater number of surgeons and/or resident physicians to involve themselves on the platform, but rather the involvement of governing bodies and spine societies to put out position statements for our patients.

"Top 20" residency-trained academic orthopaedic surgeons have higher academic productivity and funding in their careers.

"Top 20" status on Doximity, an online networking service for medical professionals, is an indicator of the reputation of a residency program. The study assesses how training at a Top 20 (T20) orthopaedic residency program impacts career productivity and funding. Fellowship and Residency Electronic Interactive Database was used in 2022 to identify active orthopaedic residency programs. Demographic and training data was collected for each orthopaedic surgeon using institutional websites and Doximity. The Residency Navigator feature on Doximity was used to rank residency programs by "reputation." Programs were categorized as either T20 or non-T20. The relative citation ratio (RCR) was calculated using the NIH iCite tool and Hirsch index (h-index) was calculated using Scopus. Industry funding was collected from the Centers for Medicare & Medicaid Services Open Payments Program (CMS) for all available years (2014-2020). A total of 2812 academic orthopaedic surgeons were included in the study. Among academic orthopaedic surgeons in the United States, T20 trained orthopedists had more publications and citations (p < 0.001), along with higher h-indices (p < 0.001), RCR (p < 0.001), and industry funding (p = 0.043). Additionally, T20 trained orthopedists were 1.375 times more likely to obtain professor status (95% confidence interval: 1.150-1.645, p < 0.001). Even after propensity-matched analysis, T20 trained orthopedists maintained these differences. Training at a T20 residency program is associated with promotion, productivity, and funding. These findings are especially of concern to medical students who must consider the importance of a residency program's reputation when deciding where to apply for residency.

Analysis of Academic Accomplishments and Demographics for Elected Presidents of National Orthopedic Surgery Organizations in the United States.

This study analyzed the academic accomplishments and demographics of elected presidents of the American Academy of Orthopaedic Surgeons (AAOS), American Orthopaedic Association (AOA), and American Board of Orthopaedic Surgery (ABOS). Curriculum vitae and internet-based resources were reviewed to collect demographics, training characteristics, bibliometrics, and National Institutes of Health (NIH) research funding of contemporary presidents (1990-2020). Eighty presidents were included. Most presidents were men (97%), and 4% of presidents were non-White (3% Black and 1% Hispanic). Few had an additional graduate degree (4% MBA, 3% MS, 1% MPH, 1% PhD). Ten orthopedic surgery residency programs trained 47% of these presidents. Most had fellowship training (59%), and the top three were hand surgery (11%), pediatric orthopedics (11%), and adult reconstruction (10%). Twenty-nine presidents (36%) participated in a traveling fellowship. The mean age at appointment was 58±5 years, which was 27 years since residency graduation. The mean h-index was 36±23, resulting from 150±126 peer-reviewed manuscripts. Orthopedic surgery presidents had more peer-reviewed manuscripts (150±126) than chairs (73±81) and program directors (27±32) (P<.001). AOA presidents had the highest mean h-index (42±21) compared with AAOS (38±27) and ABOS (25±16) presidents (P=.035). Nineteen presidents had NIH funding (24%). More presidents had NIH funding in the AOA (39%) and AAOS (25%) than the ABOS (0%) (P=.007). Orthopedic surgery presidents possess high levels of scholarly output. AOA presidents had the highest h-index values and prevalence of NIH funding. Females and racial minorities remain underrepresented at the highest levels of leadership. [Orthopedics. 2024;47(1):e45-e51.].

Overcoming the Barriers to Diversity in Orthopaedic Surgery: A Global Perspective.

BACKGROUND: Diversity in orthopaedics continues to lag behind that in other surgical specialties. This pattern exists globally and is not unique to gender or race. This review offers a global perspective on overcoming the barriers to diversity in orthopaedics. METHODS: A literature search of MEDLINE and Embase was conducted and a narrative review was undertaken. Publications that discussed any aspect of diversity or solutions to diversity within orthopaedics or academic orthopaedics were identified. RESULTS: A total of 62 studies were included. Studies showed that diversity in orthopaedic training is limited by structural barriers such as long hours, requirements to relocate during training, training inflexibility, and a lack of exposure to orthopaedics. Implicit bias during the selection process for training, discrimination, and a lack of role models are additional barriers that are experienced by both minority and female surgeons. The global lack of diversity suggests that there are also inherent "cultural barriers" that are unique to orthopaedics; however, these barriers are not uniformly experienced. Perceptions of orthopaedics as promoting an unhealthy work-life balance and the existence of a "boys' club" must be addressed. Strong, committed leaders can embed cultural norms, support trainees, and act as visible role models. Targeted efforts to increase diverse recruitment and to reduce bias in selection processes for medical school and specialty training will increase diversity in the "training pipeline." CONCLUSIONS: Diversity in orthopaedics continues to lag behind that in other specialties. Increasing diversity is important for providing a more inclusive training environment, improving patient care, and reducing health disparities. Structural and cultural barriers need to be addressed to improve diversity in orthopaedics. Promoting a culture supportive of all surgeons is essential to reframing perceptions that may prevent individuals from even considering a career as an orthopaedic surgeon. Changing attitudes require focused efforts from committed leadership in a "top-down" approach that prioritizes diversity. The efforts from national bodies seeking to tackle the lack of diversity, as well as the establishment of organizations committed to diversity, such as the International Orthopaedic Diversity Alliance, provide reasons to be optimistic for the future.

Comparison of Differences in Surgical Complications Between Fellowship-Trained Orthopedic Foot and Ankle Surgeons and All Other Orthopedic Surgeons Using the ABOS Database.

During the past decade, US orthopedic residency graduates have become increasingly subspecialized presumably for decreased patient complications; however, no study has examined this clinical utility for foot and ankle (F&A) surgeries among different fellowship subspecialties. Data from American Board of Orthopaedic Surgery 1999 to 2016 Part II Board Certification Examinations were used to assess patients treated by F&A fellowship-trained, trauma fellowship-trained, and all other fellowship-trained orthopedic surgeons performing ankle fracture repair. Adverse events were compared by surgical complexity and fellowship status. Factors independently associated with surgical complications were identified using a binary multivariate logistic regression. A total of 45,031 F&A cases met inclusion criteria. From 1999 to 2016, the percentage of F&A procedures performed by F&A fellowship surgeons steadily increased. Surgical complications were significantly different between fellowship trainings (F&A, 7.23%; trauma, 6.65%; and other, 7.84%). This difference became more pronounced with more complicated fracture pattern. On multivariate regression, F&A fellowship training was associated with significantly decreased likelihood of surgeon-reported complications (odds ratio, 0.83; 95% CI, 0.76-0.92; P<.001), as was trauma fellowship training (odds ratio, 0.90; 95% CI, 0.81-0.99; P=.035). Despite presumed increased complexity of cases treated by F&A fellowship-trained surgeons, these patients had significantly decreased risk of surgeon-reported surgical complications, thus highlighting the value of F&A fellowship training. In the absence of vital patient comorbidity data in the American Board of Orthopaedic Surgery database, further research must examine specific patient comorbidities and case acuity and their influence on treatments and surgical complications between fellowship-trained and other orthopedic surgeons to further illuminate the value of subspecialty training. [Orthopedics. 2023;46(4):e237-e243.].

Early-Career Sports Medicine Surgeons Perform a Large Volume of Non-Sports Medicine Procedures: American Board of Orthopaedic Surgery (ABOS) Part-II Data Regarding Orthopaedic Surgeons Specializing in Sports Medicine.

BACKGROUND: The purpose of this study was to utilize the American Board of Orthopaedic Surgery (ABOS) Part-II Case List database to (1) define the practice patterns of sports medicine-trained ABOS Part- II Oral Examination Candidates and (2) describe the frequency and practice patterns of individuals who are dual fellowship-trained sports medicine candidates. METHODS: The ABOS Part-II Case List database was utilized to define all cases submitted by 3,298 applicants indicating completion of a sports medicine fellowship between January 1, 2003, and January 1, 2020. Cases were classified by subspecialty category and case type. The frequency and practice patterns of candidates pursuing additional fellowship training (i.e., "dual fellowship-trained") were recorded. Descriptive statistical methods were used to describe the annual and overall procedure volume and candidate case mix. Trends in the relative frequency of cases performed and fellowship training patterns were determined using linear regression analysis. RESULTS: On average, sports medicine-trained candidates submitted 100.6 cases for review during the 6-month case collection period: 59.0 (58.6%) sports medicine/arthroscopy cases, 29.3 (29.1%) trauma/general cases, 4.5 (4.5%) adult reconstruction cases, and 7.8 (7.8%) "other" cases per candidate. Although candidates performed fewer total (r 2 = 0.84, p < 0.001) and sports medicine/arthroscopy (r 2 = 0.85, p < 0.001) cases over the study period, the proportion of sports medicine/arthroscopy cases did not change over the study period (p = 0.18). Dual fellowship training was indicated by 333 individuals (10.1%). The number of dual fellowship-trained candidates pursuing additional fellowship training in pediatrics and adult reconstruction increased over the study period, and the number of dual fellowship-trained candidates pursuing additional fellowship training in trauma decreased over the study period. CONCLUSIONS: Early-career sports medicine candidates are likely to perform >40% of cases outside of the sports medicine subspecialty. Sports medicine trainees are increasingly likely to pursue a second fellowship in pediatrics or adult reconstruction. LEVEL OF EVIDENCE: Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Objects in Mirror Are Closer Than They Appear: Symptoms of Depression and Suicidality in Orthopaedic Surgeons.

BACKGROUND: Suicide and depression among orthopaedic surgeons have recently emerged as rising concerns. Prior research has suggested that orthopaedic surgeons have the highest prevalence of suicide among surgical specialties. We sought to determine the factors associated with depression and suicidal ideation (SI) in orthopaedics, including subspecialty. METHODS: A survey including demographic questions, the Beck Depression Inventory, and the Columbia-Suicide Severity Rating Scale was administered electronically via a listserv to the orthopaedic subspecialties of trauma, adult reconstruction, hand and upper extremity, shoulder and elbow, foot and ankle, spine, pediatrics, sports medicine, and oncology. The responses were quantified according to previously published criteria. The associations of demographic factors, training, and current practice environment with depression and suicidality were assessed using Fisher exact tests. Reverse stepwise multivariable logistic regression models were developed to identify factors associated with depression and SI. RESULTS: The responses were obtained from 661 board-certified, practicing orthopaedic surgeons. In this study, 156 surgeons (23.6%) endorsed some level of active SI in their lifetime, 200 surgeons (30.3%) reported either active or passive SI in their lifetime, and 33 surgeons (5%) reported that, on at least 1 occasion in their lifetime, they had experienced active SI with a specific plan and intention to harm themselves. Gender, relationship status, having children, and residency and/or current practice region were significantly associated with depression and/or SI. Younger age, divorce, adult reconstruction and foot and ankle subspecialties, and attending residency in the Western U.S. were found on multivariable testing to be associated with symptoms of depression and SI (odds ratios, 1.03 [per 1-year decrease in age] to 8.28). CONCLUSIONS: Symptoms of depression and suicidality are not uncommon among orthopaedic surgeons, and variation by gender, relationship status, and geographic location are supported by prior research. Based on our results, depression and/or SI likely affect someone close to you or someone with whom you work. The normalization of discussions surrounding emotional well-being, depression, and SI is imperative.

Discrepancies in Work-Family Integration Between Female and Male Orthopaedic Surgeons.

BACKGROUND: Female surgeons, representing 6.5% of the American Academy of Orthopaedic Surgeons, are particularly vulnerable to work-family conflict. This conflict may deter women from considering orthopaedic surgery as a specialty. The study objective was to identify differences in work-family integration between female and male orthopaedic surgeons in the United States. METHODS: An anonymous survey collecting data within the domains of work, family, and satisfaction was completed by 347 orthopaedic surgeons (153 female, 194 male). Differences in responses between males and females were identified. RESULTS: Female surgeons were younger than males (mean, 41.1 versus 50.1 years; p < 0.001) and earlier in their careers, with 60.3% of males in practice >10 years compared with 26.1% of females (p < 0.001). Consulting (7.8% versus 31.4%; p < 0.001), course faculty positions (19.0% versus 39.2%; p < 0.001), and academic and leadership titles (30.7% versus 47.4%; p = 0.002) were significantly less common among females. There was a significant income disparity between females (mean yearly income, $300,000 to $400,000) and males (mean, $400,000 to $500,000; p < 0.001). Females were more likely to have never married (12.4% versus 2.6%; p < 0.001), or they married at a later mean age (30.2 ± 4.7 versus 28.3 ± 3.9 years; p < 0.001). Females were more likely to have no children (29.4% versus 7.8%; p < 0.001), require fertility treatment (32.0% versus 11.9%; p < 0.001), and not have children until after completing their medical training (63.0% versus 31.1%; p < 0.001). Female surgeons reported more responsibility in parenting (p < 0.001) and household duties (p < 0.001) than males. Work-family balance satisfaction was 72.3% in females and 82.1% in males (p = 0.081). CONCLUSIONS: This study highlights deficiencies in work-family integration that appear to uniquely impact female orthopaedic surgeons. Female surgeons delay starting a family, more frequently require fertility treatments, carry more responsibility at home, have fewer academic and leadership roles, earn lower incomes, and are less satisfied with work-family balance relative to males. The discrepancy in work-family integration must be addressed to attract, support, and retain women as successful orthopaedic surgeons.

Training the New Generations of Orthopaedic Surgery Residents: Understanding Generational Differences to Maximize Educational Benefit.

ABSTRACT: Most of the current orthopaedic residents are considered Millennials (born between 1981 and 1996) and are often trained by attending surgeons who are from Generation X (born between 1965 and 1980) or the Baby Boomer generation (born between 1946 and 1964). The Generation X orthopaedic surgeons were largely trained by Baby Boomers who were very demanding of their trainees and expected excellence. The Baby Boomers had been inspired, mentored, and trained by the Greatest Generation (born between 1901 and 1927). Baby Boomers took nothing for granted and nothing was given to them on a silver platter. Generation X was trained under these premises and was expected to abide by similar values. Regarding the next generation of residents, current faculty hope to instill the same qualities that had been instilled in them during their training. This value transference sometimes presents a challenge because of the differences in attitudes and perspectives that may exist between Millennial residents and their predecessors regarding work-life balance, teaching styles, the regulation of duty hours, and feedback assessments. These differences require an evolution in the methods of surgical education to optimize the educational benefit and ensure good will and rapport between the generations. Trainees and faculty alike have a responsibility to understand each other's differences and come together to ensure that knowledge, experience, values, and skill sets are effectively passed on to a new generation of orthopaedic surgeons.

Next Steps: Advocating for Women in Orthopaedic Surgery.

Orthopaedic surgery is the least diverse of all medical specialties, by both sex and race. Diversity among orthopaedic trainees is the lowest in medicine, and growth in percentage representation is the lowest of all surgical subspecialties. Women comprise only 6% of orthopaedic surgeons and 16% of orthopaedic surgery trainees. This extreme lack of diversity in orthopaedics limits creative problem-solving and the potential of our profession. Women in orthopaedics encounter sexual harassment, overt discrimination, and implicit bias, which create barriers to training, career satisfaction, and success. Women are underrepresented in leadership positions, perpetuating the lack of diversity through poor visibility to potential candidates, which impedes recruitment. Correction will require a concerted effort, as acknowledged by the American Academy of Orthopaedic Surgeons leadership who included a goal and plan to increase diversity in the 2019 to 2023 Strategic Plan. Recommended initiatives include support for pipeline programs that increase diversity of the candidate pool; sexual harassment and implicit bias acknowledgement, education, and corrective action; and the active sponsorship of qualified, capable women by organizational leaders. To follow, women will lend insight from their diverse viewpoints to research questions, practice problems, and clinical conundrums of our specialty, augmenting the profession and improving patient outcomes.

Ruth Jackson Orthopaedic Society: Promoting Women in Orthopaedics.

The Ruth Jackson Orthopaedic Society is the oldest organization in the world, supporting women in orthopaedic surgery. The mission is to promote the professional development of women in orthopaedics throughout all stages of their careers. Essential components of the strategic plan include collaboration, communication, and education, with specific domains including diversity and inclusion, professional development, membership, research, and organizational excellence. As of 2021, there are 1,161 members, with a large focus on mentorship and scholarship, providing multiple opportunities for members to excel in orthopaedics. At the core of the Ruth Jackson Orthopaedic Society is the commitment to one another, embracing the uniqueness of being a woman in orthopaedic surgery.

The J. Robert Gladden Orthopaedic Society: Past, Present, and Future.

Officially chartered in 1998, the J. Robert Gladden Orthopaedic Society (JRGOS) is a multicultural society dedicated to improving the diversity of the orthopaedic surgeon workforce and ending disparities in musculoskeletal health care. The purpose of this article is to discuss why an organization such as the JRGOS was needed within the American Academy of Orthopaedic Surgeons and highlight the key figures in orthopaedic history who supported the formation of the JRGOS. It also highlights the present efforts of the JRGOS, which include mentorship of Black, indigenous people of color medical students, residents and fellows in training, and support of research related to disparities in musculoskeletal care. As the JRGOS enters its third decade of existence, additional partnerships with the American Academy of Orthopaedic Surgeons, American Orthopaedic Association, AALOS, Orthopaedic Diversity Leadership Consortium, RJOS, Nth Dimensions, BWOS, and industry will help to realize the dream of making the orthopaedic workforce as diverse as the United States.

Assessing the performance and learning curve of orthopaedic surgical trainees in primary total hip arthroplasty.

INTRODUCTION: The aims of this study were threefold: first, to review the surgical performance of trainees in our departments by reviewing postoperative radiographs and operative times; second, to investigate the effect of supervision and assistant grade on postoperative radiographs and operative times; and third, to monitor trainees over a 6-month period looking for changes in postoperative radiograph appearances and operative times to assess whether these parameters reflect a trainee's learning curve. METHODS: A retrospective evaluation of a continuous series of primary hip arthroplasty procedures performed by 12 trainee orthopaedic surgeons (StR) during their arthroplasty rotation. In total, 348 primary total hip replacement (pTHR) operations were performed by StRs. Operative time, acetabular cup inclination, radiological leg length discrepancy (rLLD), femoral stem alignment (FSA) and the Barrack score for cementation were evaluated. The mean number of pTHRs performed per 6-month placement was 29 (range 15-51). Operative times were available for 292 cases and all postoperative imaging was evaluated. RESULTS: The mean operative time for StRs as first-surgeon was 84.3 minutes (range 42-174 minutes). Significant differences in operative times were observed between individual StRs. As a cohort, the operative times were not affected by the level of supervision but were significantly slower when StRs were assisted by other StRs. Significant differences in rLLD, FSA and Barrack score for cementation were observed across the cohort of StRs, although this did not change at a group or individual level between the first and second halves of the 6-month placement. CONCLUSIONS: Used in isolation, postoperative radiographs and operative time are not an effective measure of the learning curve in primary hip arthroplasty, however, they may be a useful adjunct in assessing the performance of orthopaedic trainees when learning primary hip arthroplasty.

How Long Will It Take to Reach Gender Parity in Orthopaedic Surgery in the United States? An Analysis of the National Provider Identifier Registry.

BACKGROUND: Although previous studies have evaluated how the proportion of women in orthopaedic surgery has changed over time, these analyses have been limited by small sample sizes, have primarily used data on residents, and have not included information on growth across subspecialties and geographic regions. QUESTION/PURPOSE: We used the National Provider Identifier registry to ask: How have the (1) overall, (2) regional, and (3) subspecialty percentages of women among all currently practicing orthopaedic providers changed over time in the United States? METHODS: The National Provider Identifier Registry of the Centers for Medicare and Medicaid Services (CMS) was queried for all active providers with taxonomy codes pertaining to orthopaedic subspecialties as of April 2020. Women orthopaedic surgeons were identified among all physicians with subspecialty taxonomy codes. As all providers are required to provide a gender when applying for an NPI, all providers with queried taxonomy codes additionally had gender classification. Our final cohort consisted of 31,296 practicing orthopaedic surgeons, of whom 8% (2363 of 31,296) were women. A total of 11,714 (37%) surgeons possessed taxonomy codes corresponding with a specific orthopaedic subspecialty. A univariate linear regression analysis was used to analyze trends in the annual proportions of women who are active orthopaedic surgeons based on NPI enumeration dates. Specifically, annual proportions were defined using cross-sections of the NPI registry on December 31 of each year. Linear regression was similarly used to evaluate changes in the annual proportion of women orthopaedic surgeons across United States Census regions and divisions, as well as orthopaedic subspecialties. The national growth rate was then projected forward to determine the year at which the representation of women orthopaedic surgeons would achieve parity with the proportion of all women physicians (36.3% or 340,018 of 936,254, as determined by the 2019 American Medical Association Physician Masterfile) and the proportion of all women in the United States (50.8% or 166,650,550 of 328,239,523 as determined by 2019 American Community Survey from the United States Census Bureau). Gender parity projections along with corresponding 95% confidence intervals were calculated using the Holt-Winters forecasting algorithm. The proportions of women physicians and women in the United States were assumed to remain fixed at 2019 values of 36.3% and 50.8%, respectively. RESULTS: There was a national increase in the proportion of women orthopaedic surgeons between 2010 and 2019 (r2 = 0.98; p < 0.001) at a compound annual growth rate of 2%. Specifically, the national proportion of orthopaedic surgeons who were women increased from 6% (1670 of 26,186) to 8% (2350 of 30,647). Assuming constant growth at this rate following 2019, the time to achieve gender parity with the overall medical profession (that is, to achieve 36.3% women in orthopaedic surgery) is projected to be 217 years, or by the year 2236. Likewise, the time to achieve gender parity with the overall US population (which is 50.8% women) is projected to be 326 years, or by the year 2354. During our study period, there were increases in the proportion of women orthopaedic surgeons across US Census regions. The lowest growth was in the West (17%) and the South (19%). Similar growth was demonstrated across census divisions. In each orthopaedic subspecialty, we found increases in the proportion of women surgeons throughout the study period. Adult reconstruction (0%) and spine surgery (1%) had the lowest growth. CONCLUSION: We calculate that at the current rate of change, it will take more than 200 years for orthopaedic surgery to achieve gender parity with the overall medical profession. Although some regions and subspecialties have grown at comparably higher rates, collectively, there has been minimal growth across all domains. CLINICAL RELEVANCE: Given this meager growth, we believe that substantive changes must be made across all levels of orthopaedic education and leadership to steepen the current curve. These include mandating that all medical school curricula include dedicated exposure to orthopaedic surgery to increase the number of women coming through the orthopaedic pipeline. Additionally, we believe the Accreditation Council for Graduate Medical Education and individual programs should require specific benchmarks for the proportion of orthopaedic faculty and fellowship program directors, as well as for the proportion of incoming trainees, who are women. Furthermore, we believe there should be a national effort led by American Academy of Orthopaedic Surgeons and orthopaedic subspecialty societies to foster the academic development of women in orthopaedic surgery while recruiting more women into leadership positions. Future analyses should evaluate the efficacy of diversity efforts among other surgical specialties that have achieved or made greater strides toward gender parity, as well as how these programs can be implemented into orthopaedic surgery.