National Trends in Orthopaedic Pain Management from 2016 to 2020.

INTRODUCTION: Effective pain management is vital in orthopaedic care, impacting postoperative recovery and patient well-being. This study aimed to discern national and regional pain prescription trends among orthopaedic surgeons through Medicare claims data, using geospatial analysis to ascertain opioid and nonopioid usage patterns across the United States. METHODS: Physician-level Medicare prescription databases from 2016 to 2020 were filtered to orthopaedic surgeons, and medications were categorized into opioids, muscle relaxants, anticonvulsants, and NSAIDs. Patient demographics were extracted from a Medicare provider demographic data set, while county-level socioeconomic metrics were obtained primarily from the American Community Survey. Geospatial analysis was conducted using Geoda software, using Moran I statistic for cluster analysis of pain medication metrics. Statistical trends were analyzed using linear regression, Mann-Whitney U test, and multivariate logistic regression, focusing on prescribing rates and hotspot/coldspot identification. RESULTS: Analysis encompassed 16,505 orthopaedic surgeons, documenting more than 396 million days of pain medication prescriptions: 57.42% NSAIDs, 28.57% opioids, 9.84% anticonvulsants, and 4.17% muscle relaxants. Annually, opioid prescriptions declined by 4.43% ( P < 0.01), while NSAIDs rose by 3.29% ( P < 0.01). Opioid prescriptions dropped by 210.73 days yearly per surgeon ( P < 0.005), whereas NSAIDs increased by 148.86 days ( P < 0.005). Opioid prescriptions were most prevalent in the West Coast and Northern Midwest regions, and NSAID prescriptions were most prevalent in the Northeast and South regions. Regression pinpointed spine as the highest and hand as the lowest predictor for pain prescriptions. DISCUSSION: On average, orthopaedic surgeons markedly decreased both the percentage of patients receiving opioids and the duration of prescription. Simultaneously, the fraction of patients receiving NSAIDs dramatically increased, without change in the average duration of prescription. Opioid hotspots were located in the West Coast, Utah, Colorado, Arizona, Idaho, the Northern Midwest, Vermont, New Hampshire, and Maine. Future directions could include similar examinations using non-Medicare databases.

Orthopaedic Trauma Research Priorities in Latin America: Developing Consensus Through a Modified Delphi Approach.

BACKGROUND: Despite a substantial burden of musculoskeletal injury, orthopaedic trauma studies in Latin America are lacking. The purpose of the present study was to identify research priorities among orthopaedic trauma surgeons in Latin America. METHODS: Research questions were solicited from members of the Asociación de Cirujanos Traumatólogos de las Américas. Participants rated questions by importance from 1 to 9. All questions were redistributed with an aggregate rating, and participants rerated questions with knowledge of group responses. RESULTS: Seventy-eight participants completed the first survey and were included in subsequent surveys. The mean age was 51.8 years, and most participants were male (92%), had completed an orthopaedic trauma fellowship (60.3%), and participated in research (80.8%). Seventeen countries were represented; 5 respondents were from a high-income country, 67 were from an upper middle-income country, and 6 were from a lower middle-income country. Sixty-five questions were identified. Six questions were rated from 1 to 3 ("more important") by >70% of participants: (1) What is the optimal treatment protocol for elderly patients with hip fracture? (2) What is the most effective initial and definitive management of musculoskeletal injury, including timing and surgical strategy, for the polytraumatized patient? (3) What is the ideal state of open fracture treatment, including timeliness and method of antibiotics, debridement, surgical fixation, and closure or coverage, at each hospital level in the health-care system? (4) What patient and fracture characteristics predict infection after musculoskeletal injury? (5) What is the current state of treatment for fracture-related infection, including timeliness and method of antibiotics and surgical intervention, at each hospital level in the health-care system? (6) What is the optimal protocol for temporary management for the hemodynamically unstable patient with a pelvic or acetabular fracture? CONCLUSIONS: This modified Delphi study of orthopaedic trauma surgeons in Latin America identified geriatric hip fractures, polytrauma, open fractures, musculoskeletal infection, and pelvic and acetabular fractures as top research priorities. This information is important for resource allocation and goal setting for orthopaedic trauma in the region.

COVID-19 Impact on Orthopedic Surgeons: Elective Procedures, Telehealth, and Income.

OBJECTIVES: The purpose of this study was to investigate the response in orthopedic surgery to the coronavirus disease 2019 (COVID-19) pandemic across the United States by surveying surgeons about their care setting, timing of restrictions on elective surgery, use of telehealth, and estimated economic impact. METHODS: A survey was distributed via REDCap through state orthopedic organizations between April and July 2020. The 22-question digital survey collected information regarding restrictions on elective procedures, location of care, utilization of telehealth, and estimated reductions in annual income. RESULTS: In this study, 192 participants responded to the survey (average age 49.9 ± 11.0 years, 92.7% male). Responses primarily originated from Alabama (30.2%), Georgia (30.2%), and Missouri (16.1%). The remainder of the responses were grouped into the category "other." Respondents did not vary significantly by state in operative setting or income type (salary, work relative value units, or collections). Most of the participants documented elective procedure restrictions in hospital and ambulatory settings. The highest frequency of closures occurred between March 18 and 20 (47% in hospital, 51% in ambulatory). Of the participants, financial loss estimates varied across states (P = 0.005), with 50% of physicians claiming >50% losses of income in Alabama (24% Georgia, 10% Missouri, 31% other). Regarding telehealth, practices set up for these services before 2020 varied across states. None of the orthopedic practices in Alabama had telehealth before the COVID-19 pandemic (Missouri 25%, Georgia 9%, other 8%, P = 0.06); however, respondents generally were split when considering the anticipation of implementing telehealth into routine practice. CONCLUSIONS: Most practices did implement restrictions for elective clinic visits and procedures early during the pandemic. COVID-19 ultimately will result in a large revenue loss for elective orthopedic practices. Services such as telehealth may help offset these losses and help deliver orthopedic care to patients remotely.

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.

Has the Volume and Variability of Procedures Reported by Fellows in ACGME-accredited Musculoskeletal Oncology Fellowship Programs Changed Over Time?

BACKGROUND: There has been a considerable rise in the number of musculoskeletal/orthopaedic oncology fellowships and subsequently, orthopaedic oncologists, in the nation. National societies have been concerned that the increasing number of orthopaedic oncologists, coupled with a limited number of patients with bone and soft-tissue sarcomas in the country, may have led to an unintended impact on the training spectrum and/or exposure of orthopaedic oncology fellows-in-training over time. Fellows who are unable to gain exposure by operating on varied cancer presentations during training may be less confident in dealing with a wide array of patients in their practice. Despite these concerns, the volume and variability of procedures performed by fellows-in-training remains unknown. Understanding these parameters will be helpful in establishing policies for standardizing training of prospective fellows to ensure they are well-equipped to care for patients with bone and/or soft-tissue sarcomas in the beginning of their career. QUESTIONS/PURPOSES: (1) Has the median surgical procedure volume per fellow changed over time? (2) How much variability in procedural volume exists between fellows, based on the most recent (2017) Accreditation Council on Graduate Medical Education (ACGME) procedure log data? (3) What proportion of fellows are meeting the minimum procedure volume thresholds, as recommended by the Musculoskeletal Tumor Society (MSTS)? METHODS: The 2010 to 2017 ACGME fellowship procedure logs for musculoskeletal oncology fellowships were retrieved from the council's official website. All fellows enrolled in ACGME-accredited fellowships are mandated to complete case logs before graduation. This study did not include operative procedures performed by fellows in nonACGME-approved fellowship programs. The 2010 to 2016 anatomic site-based procedure log data were used to evaluate fellows' overall and location-specific median operative or patient volume, using descriptive statistics. Linear regression analyses were used to assess changes in the median procedure volume over time. The 2017 categorized procedure log data were used to assess variability in procedure volume between the lowest (10th percentile) and highest (90th percentile) of all fellows. Using 2017 procedure logs, we compared the minimum procedure volume standards, as defined by the MSTS, against the number of procedures performed by fellows across the 10th, 30th, 50th (median), 70th, and 90th percentiles. RESULTS: There was no change in the median (range) procedural volume per fellow from 2010 (292 procedures [131 to 634]) to 2017 (312 procedures [174 to 479]; p = 0.58). Based on 2017 categorized procedure log data, there was considerable variability in procedural volume between the lowest (10th) percentile and highest (90th) percentile of fellows across programs: pediatric oncologic procedures (10-fold difference), surgical management of complications from limb-salvage surgery (sevenfold difference), soft-tissue resections or reconstructions (fourfold difference), bone sarcoma resections or limb-salvage surgery (fourfold difference), and spine, sacrum, and pelvis procedures (threefold difference). A fair proportion of fellows did not meet the minimum procedure volume standards, as recommended by the MSTS across certain categories. For the spine and pelvis (minimum = 10 procedures), fellows in the lowest 10th percentile performed only six procedures. For patients with bone sarcomas or limb salvage (minimum = 20 procedures), fellows in the lowest 10th percentile performed only 14 procedures. For pediatric patients with oncologic conditions (minimum = 15 procedures), fellows in the 50th percentile (13 procedures) and below failed to meet the thresholds. For surgical management of complications from limb-salvage procedures (minimum = five procedures), fellows in the lowest 10th percentile performed only three procedures. CONCLUSION: Although we were encouraged to observe that the median number of procedures performed by musculoskeletal oncology fellows over this time has not changed, we observed wide variability in the procedure volume among fellows for pediatric sarcomas, soft-tissue resection and reconstruction, limb salvage procedures, and spine procedures. We do not know how this compares with fellows trained in nonaccredited fellowship programs. CLINICAL RELEVANCE: Although we recognize that the education of fellows entails much more than performing operations, national societies have recognized a need to bring about more uniformity or standardization of training in musculoskeletal oncology. Limiting the number of orthopaedic oncology fellowships to high-volume institutions, expanding the training time period, and/or introducing subspecialty certification may be possible avenues through which standardization of training can be defined.

Is the Distribution of Awards Gender-balanced in Orthopaedic Surgery Societies?

BACKGROUND: Society awards provide visibility and national recognition for physicians. Several studies have found that women were underrepresented as award recipients when compared with subspecialty workforce data. However, to our knowledge no studies have examined the gender distribution of award recipients in orthopaedic societies. Orthopaedic surgery remains among the least gender-diverse specialties in medicine. Particularly in academic practice, the increasing paucity of women with progressive rank may reflect unequal access to the currency for promotion, including national reputation and visibility. Therefore, information on orthopaedic awarding practices may help to identify and address challenges associated with recruiting, retaining, and promoting women in orthopaedics. QUESTIONS/PURPOSES: (1) Since the year 2000, have women orthopaedic surgeons received awards in proportion to their society membership? (2) Are the awards granted to women equally distributed across the categories of leadership, humanitarianism, education, scientific investigation, resident/fellow scientific investigation, and diversity? (3) Does the gender distribution of award recipients differ for awards bestowed through a blinded process versus an unblinded process? METHODS: Eighteen national, clinically focused orthopaedic societies in the United States were included. These societies offer a combined total of 69 awards; each award was studied from its earliest record through December 2018, resulting in a study period from 1973 to 2018. Each society provided the gender demographics of their membership in 2018. The proportion of women award recipients from 2000 to 2018 was compared with the proportion of women members in 2018 for each society. Awards were also categorized based on the six types of accomplishment they recognized (leadership, humanitarianism, education, scientific investigation, resident/fellow scientific investigation, and diversity), and whether they were granted through a blinded or unblinded selection process. Chi-square tests were used to compare the proportion of women receiving awards in various categories, and to compare the proportion of women who received awards through blinded selection processes versus unblinded selection processes. RESULTS: From 2000 to 2018, women received 8% (61 of 794) of all awards and represented 9% (5359 of 59,597) of all society members. Two societies had an underrepresentation of women award recipients compared with their society membership. We found that women were not represented proportionally across award categories. Women were more likely to receive a diversity award than a leadership award (odds ratio 12.0 [95% CI 3.1 to 45.7]; p < 0.001), and also more likely to receive an education award than a leadership award (OR 4.1 [95% CI 1.3 to 12.7]). From 1973 to 2018, 17 of 22 the leadership awards offered by societies have never been granted to a woman. Finally, women were more likely to receive awards bestowed through a blinded process than an unblinded process. Women earned 11% (30 of 285) of awards bestowed through a blinded award process and 6% (31 of 509) of awards bestowed through an unblinded award process (OR 1.8 [95% CI 1.1 to 3.1]; p = 0.03). CONCLUSION: The percent of women award recipients was generally proportional to membership overall and in most societies. However, on a national workforce level, the proportion of women award recipients is lower than the proportion of women in academic orthopaedics, which has been reported by others to be about 13%, suggesting that women in academic orthopaedics may be underrepresented as award recipients. Additionally, women were less likely to receive leadership awards than awards of other types, which suggests that women are not being recognized as leaders in orthopaedics. Women were also more likely to receive awards granted through unblinded processes, which raises concern that there may be implicit bias in orthopaedic awarding practices. CLINICAL RELEVANCE: We encourage societies to examine the inclusiveness of their awards selection processes and to track the demographic information of award recipients over time to measure progress toward equal representation. Creating standardized award criteria, including women on selection committees, requiring the consideration of diverse nominees, and implicit bias training for selection committees may help to reduce bias in awarding practices.

Update on workforce diversity in vascular surgery.

OBJECTIVE: Creating a diverse workforce is paramount to the success of the surgical field. A diverse workforce allows us to meet the health needs of an increasingly diverse population and to bring new ideas to spur technical innovation. The purpose of this study was to assess trends in workforce diversity within vascular surgery (VS) and general surgery (GS) as compared with orthopedic surgery (OS)-a specialty that instituted a formal diversity initiative over a decade ago. METHODS: Data on the trainee pool for VS (fellowships and integrated residencies), GS, and OS were obtained from the U.S. Graduate Medical Education reports for 1999 through 2017. Medical student demographic data were obtained from the Association of American Medical Colleges U.S. medical school enrollment reports. The representation of surgical trainee populations (female, Hispanic, and black) was normalized by their representation in medical school. We also performed the χ2 test to compare proportions of residents over dichotomized time periods (1999-2005 and 2013-2017) as well as a more sensitive trend of proportions test. RESULTS: The proportion of female trainees increased significantly between the time periods for the three surgical disciplines examined (P < .001). Hispanic trainees also represented an increasing proportion of all three disciplines (P ≤ .001). The proportion of black trainees did not significantly change in any discipline between the two periods. Relative to their proportion in medical school, Hispanic trainees were well represented in all surgical specialties studied (normalized ratio [NR], 0.95-1.52: 0.95 OS, 1.00 GS, 1.53 VS fellowship, and 1.23 VS residency). Compared with their representation in medical school, women were under-represented as surgical trainees (NR: 0.32 OS, 0.82 GS, 0.56 VS fellowship, and 0.78 VS residency) as were black trainees (NR: 0.63 OS, 0.90 GS, 0.99 VS fellowship, and 0.81 VS residency). CONCLUSIONS: Although there were significant increases in the number of women and Hispanic trainees in these three surgical disciplines, only Hispanic trainees enter the surgical field at a rate higher than their proportion in medical school. The lack of an increase in black trainees across all specialties was particularly discouraging. Women and black trainees were under-represented in all specialties as compared with their representation in medical school. The data presented suggest potential problems with recruitment at multiple levels of the pipeline. Particular attention should be paid to increasing the pool of minority medical school graduates who are both interested in and competitive for surgical specialties.

Innovative Educational Pathways in Spine Surgery: Advanced Virtual Reality-Based Training.

BACKGROUND: Over the past few years, a reorganization of the educational pathways has been promoted with the purpose of optimizing the acquisition of competences and their assessment, so as to reduce the risks to both health care professionals and end users. Virtual reality (VR) has been repeatedly tested, initially as a positive reinforcement for more traditional educational pathways and, more recently, as their potential substitute. The aim of this study was to demonstrate the potentiality of VR simulation training in spine surgery. METHODS: The VR simulator reproduced the lateral lumbar access to the spine. The simulation included a tutorial, the preoperative settings, and the surgical session with different levels of procedural complexity. A total of 10 users were recruited for this study: 3 senior surgeons (group A) and 7 orthopedic residents or junior orthopedic surgeons (group B). Each user completed the simulation twice. RESULTS: The user's age or previous experience with VR technology did not show any relevance. On average, the entire simulation was completed in 24'36'. Group B showed an improvement between the 2 attempts in both sessions, the preoperative settings and the surgical simulation. The number of major errors dropped from an average of 5.2 to 1.8 and from an average of 4 (maximum 6-minimum 1) to 1.4, respectively. The simulation was never interrupted because of technical bugs or adverse effects related to the technology. CONCLUSIONS: VR-based training pathways might promote a high standard of care. Our preliminary experience suggests an effective implementation of the traditional coaching process.

Are Women Proportionately Represented as Speakers at Orthopaedic Surgery Annual Meetings? A Cross-Sectional Analysis.

BACKGROUND: In spite of efforts to improve gender diversity in orthopaedic surgery, women remain underrepresented, particularly with increasing academic rank. Opportunities to speak at society meetings are an important component of building a national reputation and achieving academic promotions. However, little is known about the gender diversity of orthopaedic society annual meeting speakers. Data on this topic are needed to determine whether these speaking roles are equitably distributed between men and women, which is fundamental to equalizing professional opportunity in academic orthopaedic surgery. QUESTION/PURPOSES: (1) Is the gender diversity of invited speakers at annual orthopaedic subspecialty society meetings proportional to society membership? (2) Are there differences in the proportion of women invited to speak in technical sessions (defined as sessions on surgical outcomes, surgical technique, nonsurgical musculoskeletal care, or basic science) versus nontechnical sessions (such as sessions on diversity, work-life balance, work environment, social media, education, or peer relationships)? (3) Does the presence of women on the society executive committee and annual meeting program committee correlate with the gender diversity of invited speakers? (4) Do societies with explicit diversity efforts (the presence of a committee, task force, award, or grant designed to promote diversity, or mention of diversity as part of the organization's mission statement) have greater gender diversity in their invited speakers? METHODS: Seventeen national orthopaedic societies in the United States were included in this cross-sectional study of speakership in 2018. Each society provided the number of men and women members for their society in 2018. The genders of all invited speakers were tabulated using each society's 2018 annual meeting program. Speakers of all credentials and degrees were included. All manuscript/abstract presenters were excluded from all analyses because these sessions are selected by blinded scientific review. A Fisher's exact test was used to compare the proportion of women versus men in nontechnical speaking roles. The relationship between women in society leadership roles and women in all speaking roles was investigated using a linear regression analysis. A chi square test was used to compare the proportion of women in all speaking roles between societies with stated diversity efforts with societies without such initiatives. RESULTS: Overall, women society members were proportionately represented as annual meeting speakers, comprising 13% (4389 of 33,051) of all society members and 14% (535 of 3928) of all annual meeting speakers (% difference 0.6% [95% CI -0.8 to 1.5]; p = 0.60); however, representation of women speakers ranged from 0% to 33% across societies. Women were more likely than men to have nontechnical speaking roles, with 6% (32 of 535) of women's speaking roles being nontechnical, compared with 2% (51 of 3393) of men's speaking roles being nontechnical (OR 4.2 [95% CI 2.7 to 6.5]; p < 0.001). There was a positive correlation between the proportion of women in society leadership roles and the proportion of women in speaking roles (r = 0.73; p < 0.001). Societies with a stated diversity effort had more women as conference speakers; with 19% (375 of 1997) women speakers for societies with a diversity effort compared with 8% (160 of 1931) women speakers in societies without a diversity effort (OR 2.6 [95% CI 2.1 to 3.1]; p < 0.001). CONCLUSIONS: Although the percentage of women in speaking roles was proportional to society membership overall, our study identified opportunities to improve gender representation in several societies and in technical versus nontechnical sessions. Positioning more women in leadership roles and developing stated diversity efforts are two interventions that may help societies improve proportional representation; we recommend that all societies monitor the gender representation of speakers at their annual meetings and direct conference organizing committees to create programs with gender equity. CLINICAL RELEVANCE: Society leadership, national oversight committees, invited speakers, and conference attendees all contribute to the layers of accountability for equitable speakership at annual meetings. National steering committees such as the American Academy of Orthopaedic Surgeons Diversity Advisory Board should monitor and report conference speaker diversity data to create systemwide accountability. Conference attendees and speakers should critically examine conference programs and raise concerns if they notice inequities. With these additional layers of accountability, orthopaedic surgery annual meetings may become more representative of their society members.

Trends in open shoulder surgery among early career orthopedic surgeons: who is doing what?

BACKGROUND: The incidence of various open shoulder procedures has changed over time. In addition, various fellowships provide overlapping training in open shoulder surgery. There is a lack of information regarding the relationship between surgeon training and open shoulder procedure type and incidence in early career orthopedic surgeons. METHODS: The American Board of Orthopaedic Surgery Part-II database was queried from 2002 to 2016 for reported open shoulder procedures. The procedures were categorized as follows: arthroplasty, revision arthroplasty, open instability, trauma, and open rotator cuff. We evaluated procedure trends as well as their relationship to surgeon fellowship categorized by Sports, Shoulder/Elbow, Hand, Trauma, and "Other" fellowship as well as no fellowship training. We additionally evaluated complication data as it related to procedure, fellowship category, and volume. RESULTS: Over the 2002-2016 study period, there were increasing cases of arthroplasty, revision arthroplasty, and trauma (P < .001). There were decreasing cases in open instability and open rotator cuff (P < .001). Those with Sports training reported the largest overall share of open shoulder cases. Those with Shoulder/Elbow training reported an increasing overall share of arthroplasty cases and higher per candidate case numbers. The percentage of early career orthopedic surgeons reporting 5 or more arthroplasty cases was highest among Shoulder/Elbow candidates (P < .001). Across all procedures, those without fellowship training were least likely to report a complication (odds ratio [OR], 0.76; 95% confidence interval, 0.67-0.86; P < .001). Shoulder/Elbow candidates were least likely to report an arthroplasty complication (OR, 0.84, P = .03) as was any surgeon reporting 5 or more arthroplasty cases (OR, 0.81; 95% confidence interval, 0.70-0.94; P = .006). CONCLUSION: The type and incidence of open shoulder surgery procedures continues to change. Among early career surgeons, those with more specific shoulder training are now performing the majority of arthroplasty-related procedures, and early career volume inversely correlates with complications.

Chair Versus Chairman: Does Orthopaedics Use the Gendered Term More Than Other Specialties?

BACKGROUND: Orthopaedics is the least gender-diverse medical specialty. Research suggests that the use of gendered language can contribute to workforce disparity and that gender-neutral language supports the inclusion and advancement of women, but the degree to which gender-neutral language is used by academic departments in what typically is a department's highest position (department chair) has not been characterized. QUESTIONS/PURPOSES: (1) Is the proportion of department websites that use the term chairman (as opposed to chair) greater in orthopaedics than in five other surgical and medical specialties? (2) Are departments led by chairs who are women less likely to use "chairman" than those led by men, and does this vary by specialty? METHODS: Seven hundred fourteen official websites of orthopaedic, neurosurgery, general surgery, internal medicine, pediatrics, and obstetrics and gynecology departments affiliated with 129 allopathic medical schools were screened. Any use of the term chairman on title pages, welcome messages, and faculty profile pages was identified using a Boyer-Moore string-search algorithm and terms were classified based on their location on the site. The overall use of the term chairman was compared by specialty and gender of the chair. RESULTS: Sixty percent of orthopaedic department websites (71 of 119) used the term chairman at least once, a proportion higher than that of pediatrics (36% [46 of 128]; OR 0.38; 95% CI, 0.23 to 0.63; p < 0.001), internal medicine (31% [38 of 122]; OR 0.030; 95% CI, 0.18 to 0.53; p < 0.001), and obstetrics and gynecology (29% [37 of 126]; OR 0.28; 95% CI, 0.17 to 0.48; p < 0.001), but no different than that of neurosurgery (57% [54 of 94]; OR 0.91; 95% CI, 0.52 to 1.6; p = 0.74) and general surgery (55% [69 of 125]; OR 0.83; 95% CI, 0.50 to 1.4; p = 0.48). Across disciplines, departments whose chairs were women were much less likely to use the term chairman than departments whose chairs were men (14% [17 of 122] versus 50% [297 of 592]; OR 0.16; 95% CI, 0.09 to 0.28; p < 0.001). CONCLUSIONS: The frequent use of the term chairman in orthopaedics, coupled with the preference of women to use the term chair, suggests considerable room for growth in the use of gender-equal language in orthopaedics. CLINICAL RELEVANCE: Our current efforts to increase the number of women in orthopaedics may be undermined by gendered language, which can create and reinforce gendered culture in the field. Electing to use gender-neutral leadership titles, while a relatively small step in the pursuit of a more gender-equal environment, presents an immediate and no-cost way to support a more inclusive culture and counteract unconscious gender bias. Future studies should explore the individual attitudes of chairs regarding the use of gendered titles and identify additional ways in which biases may manifest; for example, the use of gendered language in interpersonal communications and the presence of unconscious bias in leadership evaluations. Continued efforts to understand implicit bias in orthopaedics can guide actionable strategies for counteracting gendered stereotypes of the specialty, in turn aiding initiatives to recruit and promote women in the field.

Comparison of opioid use and prescribing patterns in orthopedic surgery in Japan and the United States: A JOA-AOA Traveling Fellowship Investigation.

BACKGROUND: The US continues to be in the midst of an opioid epidemic. The prescription of narcotics for acute injury or post-operative pain is a common inciting event leading to opioid abuse and addiction. It is eminently important for orthopedic surgeons to lead the charge in changing practice patterns to decrease the prescribing and subsequent use and abuse of opioids. Anecdotally, many surgeons are aware that use of opioids for post-operative pain is substantially less in other countries compared to the US. However, this has not been well quantified and may be useful information to guide practice. METHODS: The 2018 American Orthopedic Association (AOA)- Japanese Orthopedic Association (JOA) traveling fellows developed a survey to compare orthopedic surgeon-reported opioid prescribing patterns after various common orthopedic surgeries in Japan and the US. RESULTS: We present here survey data demonstrating significantly less post-operative prescription of opioids in Japan in terms of number of pills provided and duration of prescriptions compared to orthopedic surgeons in the US. CONCLUSION: We hope this provides meaningful data to motivate orthopedic surgeons in the US to evaluate and potentially alter their own prescription habits to help mitigate the opioid crisis.

How Well Represented Are Women Orthopaedic Surgeons and Residents on Major Orthopaedic Editorial Boards and Publications?

BACKGROUND: Recent studies indicate that women are substantially underrepresented as orthopaedic surgeons and residents compared with other specialties in medicine and medical school. The reasons for this are multifactorial and not completely understood, but previous studies suggest that women may be attracted to fields in which they have female role models. Given that women interested in academia and research may use female editorship and authorship as a proxy for female representation in orthopaedic surgery, we wanted to examine the proportion of women represented in orthopaedic journals and determine if it reflects the distribution of women in orthopaedic surgery as a field. We further wanted to understand if this representation has changed over time in the setting of a slowly shifting gender landscape within orthopaedic surgery. QUESTIONS/PURPOSES: (1) How are women orthopaedic surgeons and residents represented in orthopaedic journals compared with men? (2) Have these proportions changed in the past two decades in light of relatively new efforts to recruit women to the field of orthopaedic surgery? METHODS: The gender composition of editorial boards and first and last authors were obtained from the 1997, 2007, and 2017 volumes of the following journals: The Journal of Bone & Joint Surgery (JBJS), the Journal of the American Academy of Orthopaedic Surgeons (JAAOS), and Clinical Orthopaedics and Related Research® (CORR®). Gender neutral names were searched to obtain a picture to ensure proper tallies. RESULTS: The total combined amount of women first and last authors increased from 88 of 1450 (6%) in 1997 to 152 of 1912 (8%) in 2007 to 723 of 5391 (13%) in 2017. Similarly, three of 113 (3%) editorial board members were women in 1997, three of 105 (3%) were women in 2007 and 10 of 107 (9%) editors were women in 2017. Of note, 0 out of 9 editors-in-chief were women. CONCLUSIONS: Based on the current percentage of women orthopaedic surgeons and residents, women are represented equally or in greater numbers as editors and authors in JAAOS, JBJS, and CORR. This may be in part due to women orthopaedic surgeons entering academic medicine at a greater rate than males. CLINICAL RELEVANCE: Orthopaedic surgeons serving as mentors to prospective female applicants can cite female representation on editorial boards and as authors as an example of gender parity in the field. Additionally, active orthopaedic surgeons who are women interested in these leadership positions should be encouraged that these opportunities exist, regardless of gender.

Despite Growing Number of Women Surgeons, Authorship Gender Disparity in Orthopaedic Literature Persists Over 30 Years.

BACKGROUND: The most recent demographic data reveal that only 6.5% of practicing orthopaedic surgeons are women, and as far as we know, only two women have held chair positions in academic orthopaedic programs in the United States. Furthermore, orthopaedic surgery is the least gender-diverse speciality recognized by the Accreditation Council for Graduate Medical Education. The factors that contribute to the lack of gender diversity in orthopaedics remain ill-defined. A lag in publication productivity may be a barrier to career advancement for women orthopaedic surgeons, but this has not been well studied. QUESTIONS/PURPOSES: (1) What is the proportion of orthopaedic studies published in six major orthopaedic journals by women first or senior authors from 1987 to 2017? (2) Did men and women orthopaedic surgeons publish in equal proportions during the study period (measured in 5-year intervals)? (3) Are there differences in the characteristics (such as study type or subject focus) of orthopaedic publications authored by women and those authored by men? (4) Has the increased proportion of practicing women orthopaedic surgeons been matched by an equal increase in authorship by women orthopaedic surgeons during the study timeframe? METHODS: A cross-sectional analysis was designed to characterize trends in authorship of orthopaedic studies by women over time. All publications from the first issue of each of six major orthopaedic journals were evaluated at seven time points (1987, 1992, 1997, 2002, 2007, 2012, and 2017). Characteristics of each first and senior author (including gender, academic degree, and specialty), and study category of each publication were collected. Articles for which this information was not available were excluded (35 of 1073, or 3.3% of published studies, no difference in proportion of excluded studies between journals). The proportions of women and men authors were compared at the seven time points and for six study categories (basic science, case report/technique article, clinical medicine, economics/practice management, editorial content [including true editorials, letters to the editor, commentaries, and book reviews] and review/meta-analysis) using a Fisher's exact test or chi-squared analysis. We compared the rates of change of women authorship, practicing women orthopaedic surgeons, and women orthopaedic residents during the study period using an ANOVA and Tukey's honestly significant difference (HSD) post-hoc test with Cohen's D measure of effect size. RESULTS: From 1987 to 2017, only 1.7% (15 of 880) of senior authors and 4.4% (46 of 1038) of first authors of orthopaedic publications were women orthopaedic surgeons. Based on population proportions (that is, percent of practicing women orthopaedic surgeons compared with men), the proportion of women senior authors was less than would be expected at each time point after 1987 compared with men. There were no differences between the types of studies authored by women or men. Finally, during the study period, the rate of growth of women senior authorship was less than the rates of growth of both practicing women orthopaedic surgeons (d = 5.3, 95% CI, 4.8-5.6; p = 0.023) and women first authorship (d = -4.3, 95% CI -4.6 to -3.6, p = 0.030; estimated mean 3.3, p = 0.013). CONCLUSIONS: Women orthopaedic surgeons published a small proportion of academic orthopaedic research from 1987 to 2017, and women senior authors consistently published less than would be expected based on their population proportion compared with men orthopaedic surgeons. Furthermore, the growth of practicing women orthopaedic surgeons has not been matched by growth in senior authorship by women over the same timeframe. CLINICAL RELEVANCE: This discrepancy warrants further exploration because a low rate of publication may negatively impact the career advancement of women orthopaedic surgeons and contribute to the overall lack of gender diversity in orthopaedics. We suggest that journals and publishers review their editorial processes to ensure blinding of author names during peer review and editorial decision-making, and to disclose those review processes to authors. We also suggest that institutions encourage women trainees and junior faculty to participate in mentorship programs and specialty societies that promote academic productivity.

Does the Proportion of Women in Orthopaedic Leadership Roles Reflect the Gender Composition of Specialty Societies?

BACKGROUND: Increasing the number of women in surgical subspecialties has been challenging, especially in orthopaedics, in which the percentage of women has remained relatively the same for the past several decades. Certain subspecialties, such as pediatric orthopaedics, have a greater proportion of women than other orthopaedic subspecialties do. Women in leadership roles in a specialty society (for example, on the board of directors) may serve as role models and help attract women to our specialty, leading to increased diversity. As the proportion of women in a specialty society increases, the leadership (board of directors) of the society might reflect the gender composition of that society's membership. It is not known whether gender diversity in orthopaedic societies is reflected in their leadership. QUESTION/PURPOSES: (1) Does the percentage of women members in a specialty society correlate with the percentage of women on its board of directors? (2) Does having a junior position on an orthopaedics subspecialty society's board of directors correlate with an increased percentage of women on its board of directors? METHODS: We queried the executive directors of each of the 23 societies of the Board of Specialty Societies of the American Academy of Orthopaedic Surgeons to obtain the number and percentage of women members in each society, the number of women on each society's board of directors, the criteria for becoming a board member, and the presence or absence of junior board members. All 23 societies responded. We supplemented the data by reviewing these societies' bylaws. Society bylaws were studied to determine if the presence of a junior board member affected the percentage of women on its board of directors. We correlated the percentage of women in each society with the percentage of women on that society's board of directors and compared this across the studied societies. RESULTS: We found a strong correlation between the percentage of women in a society and the percentage of women on the society's board of directors (r = .2333; p = .0495). The subspecialty society with the highest percentage of women (26%), the Pediatric Orthopaedic Society of North America, did not have the highest percentage of women on its board of directors (three of 20 members were women, 15%). The subspecialty society with the highest percentage of women on its board of directors, the Orthopaedic Research Society (seven of 16 members, 44%), did not have the highest percentage of women (25%). There was no correlation between presence of a junior board member and increased percentage of women in an orthopaedic society, nor was there a correlation between the presence of a junior board member and percentage of women on the board of directors in a society. CONCLUSIONS: There is a correlation between the number of women members in an orthopaedic specialty society and the number of women on its board of directors. The correlation is not explained by the presence of a junior member position, which may be inspiring to younger women. Although a correlation exists, we could not predictably match societies with the highest percentage of women members to those with the highest percentage of women on their boards of directors, and vice versa. This study reveals the current percentage of women in orthopaedic specialty societies and the percentage of women in leadership positions. This is the first step towards diversity of gender in orthopaedics. LEVEL OF EVIDENCE: Level III, prognostic study.

What is the Geographic Distribution of Women Orthopaedic Surgeons Throughout the United States?

BACKGROUND: Orthopaedic surgery has a shortage of women surgeons. An even geographic distribution of women orthopaedic surgeons may provide more uniform care to patients. However, little is known about the geographical distribution of women orthopaedic surgeons. QUESTIONS/PURPOSES: (1) Is there substantial geographic variation in the distribution of orthopaedic surgeons who are women? (2) How does the geographic distribution of women orthopaedic surgeons compare with that of other physicians? (3) What are the variables associated with increased region-based proportions of orthopaedic surgeons who are women? METHODS: To obtain a national snapshot of orthopaedic providers, two Medicare databases were used (Medicare Provider Utilization and Payment Data and Medicare's current and archived Physician Compare Data). These databases were used to identify physicians with self-reported specialties of "Orthopedic Surgeon," "Hand Surgeon," or "Sports Medicine" with at least 11 Medicare claims in 1 year for a single procedure type between 2012 and 2014. These databases are the only databases known to specifically report surgeon gender on a national scale and include physician demographics and education. The Dartmouth Atlas's hospital referral regions and United States Census Bureau divisions were used to group physicians by geographic region. The Gini coefficient, a measure of statistical dispersion, was used to quantify the regional distribution of orthopaedic surgeons. This was compared with the dispersion of non-orthopaedic physicians within the same Medicare databases. Surgeon and regional characteristics were correlated with the proportion of women orthopaedic surgeons in the region. RESULTS: There is substantial geographic variation in the distribution of orthopaedic surgeons who are women, ranging from 0% to 15%. There was a greater prevalence of women orthopaedic surgeons in New England (7.3%, 107 of 1469 surgeons) and the Pacific region (6.5%, 208 of 3196 surgeons) than in the South Atlantic (4.5%, 210 of 4618 surgeons) and East South Central regions (3.5%, 50 of 1442 surgeons). This represents a greater level of variation (Gini coefficient = 0.37) compared with other specialties (0.30 and 0.37) and compared with men orthopaedic surgeons (0.16). Variables independently associated with an increased prevalence of women orthopaedic surgeons based on hospital referral region were an increased proportion of currently practicing women physicians who graduated from medical schools in that region (beta = 0.03; p = 0.01), increased proportion of Medicaid-eligible patients (beta = 0.12; p = 0.002), increased proportion of regional population is black (beta = -0.06; p = 0.03), and increased regional supply of women physicians (beta = 0.26; p < 0.0001). CONCLUSIONS: Despite the recent increase in women orthopaedic surgeons nationally, gains have not been equally distributed throughout the United States. CLINICAL RELEVANCE: In other medical fields, gender diversity has been proven to be beneficial for patients. If this holds true in the field of orthopaedic surgery, we should be mindful of the geographic distribution of women orthopaedic surgeons as the percentage of these surgeons increases.