Orthopaedic Surgery Attrition Before Board Certification: A National-Cohort Study of US MD Graduates in Orthopaedic Surgery Residency Programs.

Introduction: Little is known about attrition before American Board of Orthopaedic Surgery (ABOS) board certification for orthopaedic residents training in Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedics programs. This national-cohort study examined orthopaedic surgery attrition, associated risk factors, and specialties pursued by residents who left orthopaedics. Methods: From August 2022 through July 2023, we analyzed deidentified, individual-level data from the Association of American Medical Colleges for 129,860 US MD-granting medical-school matriculants in academic years 1993 to 1994 through 2000 to 2001. Graduates with records of training ≥1 year in orthopaedic surgery during GME and of board certification as of May 2020 were included. Retention was defined as being ABOS-certified; attrition was defined as being certified by another specialty board and not ABOS. We identified variables independently associated with attrition from orthopaedics using multivariable logistic regression analysis and reported adjusted odds ratios (OR) and 95% confidence intervals (CI). Results: Of 4,319 US medical-school graduates from 1997 to 2009 with ≥1 year of orthopaedic surgery GME, 4,085 (94.6%) obtained ABOS board certification (retention) and 234 did not (attrition). Women (OR 2.8, 95% CI 2.0-3.9), first-generation college graduates (OR 1.6, 95% CI 1.1-2.2), Asians (OR 1.9, 95% CI 1.4-2.7), and residents who placed greater importance on innovation/research in choosing medicine as a career (OR 1.4, 95% CI 1.1-1.7) and completed ≥1 year of research during GME (OR 2.4, 95% CI 1.7-3.5) were more likely to leave orthopaedics. Overall, 121 trainees who left orthopaedics selected surgical specialties for board certification, most commonly plastic surgery (n = 66) and general surgery (n = 45). Conclusions: The increased risk of attrition among women, Asians, first-generation college graduates, and trainees endorsing higher importance of innovation/research in choosing medicine and participating in research during GME raises concerns about the potential loss of underrepresented groups among orthopaedic surgeons and surgeon-scientists. Efforts to mitigate attrition among residents in high-risk groups are warranted.

NAB2-STAT6 drives an EGR1-dependent neuroendocrine program in Solitary Fibrous Tumors.

The pathogenesis of many rare tumor types is poorly understood, preventing the design of effective treatments. Solitary fibrous tumors (SFTs) are neoplasms of mesenchymal origin that affect 1/1,000,000 individuals every year and are clinically assimilated to soft tissue sarcomas. SFTs can arise throughout the body and are usually managed surgically. However, 30-40% of SFTs will relapse local-regionally or metastasize. There are no systemic therapies with durable activity for malignant SFTs to date. The molecular hallmark of SFTs is a gene fusion between the NAB2 and STAT6 loci on chromosome 12, resulting in a chimeric protein of poorly characterized function called NAB2-STAT6. We use primary samples and an inducible cell model to discover that NAB2-STAT6 operates as a transcriptional coactivator for a specific set of enhancers and promoters that are normally targeted by the EGR1 transcription factor. In physiological conditions, NAB2 is primarily localized to the cytoplasm and only a small nuclear fraction is available to operate as a co-activator of EGR1 targets. NAB2-STAT6 redirects NAB1, NAB2, and additional EGR1 to the nucleus and bolster the expression of neuronal EGR1 targets. The STAT6 moiety of the fusion protein is a major driver of its nuclear localization and further contributes to NAB2's co-activating abilities. In primary tumors, NAB2-STAT6 activates a neuroendocrine gene signature that sets it apart from most sarcomas. These discoveries provide new insight into the pathogenesis of SFTs and reveal new targets with therapeutic potential.

Do Women and Minority Orthopaedic Residents Report Experiencing Worse Well-being and More Mistreatment Than Their Peers?

BACKGROUND: Despite the increased risk of attrition for women and minority residents during orthopaedic residency, there is currently a paucity of research examining the training environment of these residents. To address this, we examined how well-being constructs may differ for women or minority residents compared with their peers, and whether these residents report experiencing more mistreatment during residency. QUESTIONS/PURPOSES: (1) How does the psychologic wellbeing of women and minority residents compare with that of their peers regarding the constructs of burnout, lifestyle satisfaction, social belonging, and stereotype threat? (2) Do reported mistreatment experiences during residency differ among women and minority residents compared with their peers? (3) Is there a difference in the proportion of women and minority orthopaedic residents with thoughts of leaving residency compared with their peers? METHODS: Seventeen orthopaedic residency programs in the 91 programs comprising the Collaborative Orthopaedic Educational Research Group agreed to participate in the study. Program directors sent an anonymous one-time survey with two reminders to all orthopaedic residents at their respective institutions. The survey instrument comprised validated and previously used instruments with face validity designed to measure burnout, satisfaction, duty-hour violations, belonging, stereotype threat, mistreatment, and thoughts of leaving residency, in addition to demographic information. Forty-three percent (211 of 491) of residents responded to the survey. Race or ethnicity data were combined into "White" and "underrepresented in orthopaedics" (URiO), which included residents who self-identified as Asian, African American, Hispanic or Latino, Native American, or other, given that these groups are all underrepresented racial and ethnic groups in orthopaedics. The demographic makeup of our study, 81% men and 75% White, is roughly comparable to the current demographic makeup of orthopaedic residency programs, which is 82% men and 74% White. Data were analyzed using chi-square tests, Fisher exact tests, and t-tests as appropriate. For comparisons of Likert scale measures, we used an anchor-based approach to determining the minimum detectable change (MDC) and set the MDC as a 1-point difference on a 5-point scale and a 1.5-point difference on a 7-point scale. Stereotype threat is reported as the mean ▵ from the neutral response, and ▵ of 1.5 or greater was considered significant. RESULTS: Women residents were more likely than men to report experiencing emotional exhaustion (odds ratio 2.18 [95% confidence interval 1.1 to 4.5]; p = 0.03). Women reported experiencing stereotype threat regarding their identity as women surgeons (mean ▵ 1.5 ± 1.0). We did not identify a difference in men's and women's overall burnout (OR 1.4 [95% CI 0.7 to 3.0]; p = 0.3), lifestyle satisfaction across multiple domains, or sense of social belonging (men: 4.3, women 3.6; mean difference 0.7 [95% CI 0.4 to 0.9]; p < 0.001). We did not identify differences in overall burnout (OR 1.5 [95% CI 0.8 to 3.0]; p = 0.2), lifestyle satisfaction across multiple domains, sense of social belonging (White: 4.2, URiO: 3.9; mean difference 0.3 [95% CI 0.17 to 0.61]; p < 0.001), or stereotype threat (mean ▵ 0.8 ± 0.9) between White and URiO surgeons. Women were more likely than men to report experiencing mistreatment, with 84% (32 of 38) of women and 43% (70 of 164) of men reporting mistreatment at least a few times per year (OR 7.2 [95% CI 2.8 to 18.1]; p < 0.001). URiO residents were more likely than White residents to report experiencing mistreatment overall, with 65% (32 of 49) of URiO residents and 45% (66 of 148) of White residents reporting occurrences at least a few times per year (OR 2.3 [95% CI 1.2 to 4.6]; p = 0.01). Women were more likely than men to report experiencing gender discrimination (OR 52.6 [95% CI 18.9 to 146.1]; p < 0.001), discrimination based on pregnancy or childcare status (OR 4.3 [95% CI 1.4 to 12.8]; p = 0.005), and sexual harassment (OR 11.8 [95% CI 4.1 to 34.3]; p < 0.001). URiO residents were more likely than White residents to report experiencing racial discrimination (OR 7.8 [95% CI 3.4 to 18.2]; p < 0.001). More women than men had thoughts of leaving residency (OR 4.5 [95% CI 1.5 to 13.5]; p = 0.003), whereas URiO residents were not more likely to have thoughts of leaving than White residents (OR 2.2 [95% CI 0.7 to 6.6]; p = 0.1). CONCLUSION: Although we did not detect meaningful differences in some measures of well-being, we identified that women report experiencing more emotional exhaustion and report stereotype threat regarding their identity as women surgeons. Women and URiO residents report more mistreatment than their peers, and women have more thoughts of leaving residency than men. These findings raise concern about some aspects of the training environment for women and URiO residents that could contribute to attrition during training. CLINICAL RELEVANCE: Understanding how well-being and mistreatment affect underrepresented residents helps in developing strategies to better support women and URiO residents during training. We recommend that orthopaedic governing bodies consider gathering national data on resident well-being and mistreatment to identify specific issues and track data over time. Additionally, departments should examine their internal practices and organizational culture to address specific gaps in inclusivity, well-being, and mechanisms for resident support.

PROMIS Physical Function and Pain Interference Scores Correlate with the Lower Extremity Toronto Extremity Salvage Score.

The Toronto Extremity Salvage Score (TESS) and the National Institutes of Health Patient-Reported Outcomes Measurement Information System (PROMIS) are both utilized to measure patient-reported outcomes in adults with musculoskeletal oncologic conditions. However, the relationship between them has not been studied. We sought to describe a link between Lower Extremity (LE) TESS and PROMIS Physical Function (PF) scores, as well as between LE TESS and Pain Interference (PI) scores, to develop a method for converting scores between TESS and PROMIS and to examine whether TESS and PROMIS captured differences in pain and function between clinically relevant subgroups in our population. Methods: Our study population consisted of 125 adult patients who underwent surgical treatment of a lower-extremity musculoskeletal tumor at a single sarcoma center between December 2015 and October 2018. The LE TESS questionnaire was administered to patients via paper and the PROMIS PF and PI were administered via iPad at a preoperative appointment. The relationship between LE TESS and PROMIS measures was analyzed with use of generalized linear modeling. Subgroup analyses were performed with a 2-tailed t test or 1-way analysis of variance. Results: PROMIS PF had a very strong positive correlation with LE TESS (r = 0.83) and was related through the following equation: PROMIS PF = 0.00294 × (LE TESS)2 + 22.6. PROMIS PI had a strong negative correlation with LE TESS (r = -0.77) and was related through the following equation: PROMIS PI = -0.00259 × (LE TESS)2 + 73.8. PROMIS PF and PI performed similarly to LE TESS across multiple patient subgroups and captured the expected differences between subgroups. Conclusions: LE TESS and PROMIS PF appeared to measure similar information in patients with an orthopaedic oncologic condition. Moreover, PROMIS PI scores were strongly correlated with functional disability as measured with the LE TESS. Understanding the relationship between TESS and PROMIS will allow the comparison and combination of data for both clinical and research purposes. Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Removing or Only Moving a Barrier? Screening Applications with US Medical Licensing Examination Step 2CK Instead of Step 1 May Benefit Women but Not Underrepresented Minorities in Orthopaedics.

Most orthopaedic surgery program directors report using a minimum score cutoff for the US Medical Licensing Examination Step 1 examination when evaluating residency applicants. The transition to a Pass/Fail grading system beginning in the 2022-2023 application cycle will alter applicant evaluation in the interview selection process. The impact of this change, particularly on women and underrepresented minority (URM) applicants, remains unclear. This study was designed to evaluate how a shift to screening applications using Step 2 Clinical Knowledge (CK) instead of Step 1 scores could impact selection for residency interviews. Methods: We reviewed all 855 Electronic Residency Application Service applications submitted to the University of Pennsylvania's orthopaedic surgery residency program in the 2020-2021 cycle. Applicant age, sex, medical school of graduation, self-identified race, and permanent zip code were evaluated for association with Step 1 and Step 2CK scores using a 2-sample t test. A multivariable linear regression analysis was conducted to understand the predictive value of demographic features and medical school features on Step 1 and 2CK scores. Results: Multivariable linear regression revealed both Step 1 and 2CK scores were lower for applicants of URM status (Step 1: p < 0.001; Step 2CK: p < 0.001) and from international medical schools (p = 0.043; p = 0.006). Step 1 scores but not Step 2CK scores were lower for applicants who were women (p < 0.001; p = 0.730), ≥30 years of age (p < 0.001; p = 0.079), and from medical schools outside the top 25 in National Institutes of Health (NIH) funding or US News and World Report (USNWR) ranking (p = 0.001; p = 0.193). Conclusions: Conversion of Step 1 grading to Pass/Fail may reduce barriers for groups with lower average Step 1 scores (URM, female, ≥30 years of age, and from institutions with lower NIH funding or USNWR rankings). However, if Step 2CK scores replace Step 1 as a screening tool, groups with lower Step 2CK scores, notably URM applicants, may not experience this benefit. Level of Evidence: Level IV. See Instructions for Authors for a complete description of levels of evidence.

Factors That Influence Orthopedic Women Residents' Selection of Adult Reconstruction.

BACKGROUND: Stereotypes may discourage women from going into the historically male-dominated field of Adult Reconstruction. Other factors such as interest, confidence, and a sense of belonging may influence subspecialty choice. The objective of this study was to survey orthopedic surgery residents regarding their perceptions about Adult Reconstruction. METHODS: A validated survey evaluating social determinants of behavior was adapted to assess orthopedic surgery residents' perceptions of Adult Reconstruction. The survey was electronically distributed to residents from 16 United States and Canadian Accreditation Council for Graduate Medical Education-accredited residency programs. There were 93 respondents including 39 women (42%) and 54 men (58%). Study data were collected and managed using an electronic data capture tool. Descriptive statistics were reported for all continuous variables. Percentiles and sample sizes were reported for categorical variables. RESULTS: Women and men reported similar interest in Adult Reconstruction (46% versus 41%, P = .60). Fewer women reported that they were encouraged to go into Adult Reconstruction by faculty (62% versus 85%, P = .001). Women and men reported similar confidence in their own ability to succeed in the subspecialty of Adult Reconstruction. However, when asked about the ability of other residents, both sexes rated men as having higher levels of confidence. Women and men perceived other residents and faculty felt "men are better Adult Reconstruction surgeons," but did not personally agree with this statement. CONCLUSION: Women and men residents expressed similar rates of interest and self-confidence in Adult Reconstruction, but there were social barriers including negative stereotypes that may prevent them from pursuing careers in Adult Reconstruction.

Soft-Tissue Masses: A Visual Guide to the Good, the Bad, and the Ugly.

Benign soft-tissue masses drastically outnumber malignant tumors. Both benign and malignant soft-tissue masses can present in the same manner, as a painless growing soft-tissue lump or bump. The implications of misdiagnosing a soft-tissue sarcoma can be devastating. The most common mistake occurs when all masses are assumed to be lipomas. A careful history, physical examination, and appropriate imaging can determine the benign or malignant nature of a tumor. A mass that is large (>5 cm), deep (in relation to investing fascia), and firmer than the surrounding muscle should raise suspicion for a malignancy. Small, superficial masses are more likely to be benign, but up to 32% of soft-tissue sarcomas can present in this manner. The orthopaedic surgeon should be able to recognize common imaging findings for benign and malignant entities.

Fixation Principles for Pathologic Fractures in Metasatic Disease.

The management of pathologic fractures differs from nonpathologic fractures with respect to preoperative evaluation, surgical strategies, adjuvant therapies, and complication rates. These issues must be understood to provide appropriate musculoskeletal care for patients with metastatic disease.

Effective Mentorship of Women and Underrepresented Minorities in Orthopaedic Surgery: A Mixed-Methods Investigation.

Orthopaedic surgery is currently the least diverse medical specialty, and there is little research on the mentorship needs for women and underrepresented minorities (URMs) in orthopaedics. The purpose of this study was to examine the roles and functions of mentorship for women and URMs in orthopaedic surgery, to understand mentorship preferences, and to elucidate barriers to mentorship in orthopaedic surgery. Methods: Members of J. Robert Gladden Orthopaedic Society and Ruth Jackson Orthopaedic Society were invited to participate. An email with an anonymous link to the survey was distributed; the survey was open for responses from September 2020 through February 2021. The survey contained free-response and quantitative items about mentorship and its impact on current activities, career path, and ways to improve mentorship. Descriptive statistics, 1-way analysis of variance, frequencies, and Fisher exact test were used to analyze survey data. Qualitative data were deidentified and analyzed using thematic analysis techniques. Results: A total of 155 participants responded to the survey, of those, 151 (98%) met criteria for analysis. Sixty-four percent of participants were women, 15% identified as Black, 4% identified as Hispanic, and 9% identified as multiracial. Eighty-five percent of respondents had a mentor in orthopaedic surgery. Mentorship was often cited as useful for exposure to role models and skills development. Medical students were most likely to consider gender concordance with their mentor important. URM respondents reported greater importance of sharing race/ethnicity with their mentor (p = 0.005). In qualitative responses, participants commented on identity-specific challenges to mentorship, lack of time and institutional support for mentorship, and the disproportionate burden of mentorship on women and URMs. Conclusions: Mentorship was highly valued among women and URMs in orthopaedic surgery across all career stages. Mentorship attracted students to orthopaedic surgery and allowed residents and surgeons to progress in the field. Sharing racial/ethnic identity in mentor-mentee relationships was important to both trainees and practicing surgeons.

Examining patient perspectives on sarcoma surveillance: The Sarcoma Surveillance Survey.

OBJECTIVES: The optimal frequency and modality of sarcoma surveillance imaging are uncertain, and current practices vary substantially. While efforts to develop evidence-based guidelines are ongoing, patient perspectives regarding surveillance imaging have not been reported. The primary goal of this study was to pilot the novel Sarcoma Surveillance Survey to assess patient concerns regarding sarcoma surveillance. METHODS: In this single-center, cross-sectional study, patients receiving surveillance imaging after surgical sarcoma treatment were administered the 10-item Sarcoma Surveillance Survey, the validated Appraisal Scale, measuring positive and negative emotional reactions to imaging, and the Patient-Reported Outcomes Measurement Information System (PROMIS) Anxiety Short Form 8a as a measure of anxiety. RESULTS: Patients expressed highest levels of concern about cost and radiation exposure associated with surveillance, and most (87.6%) did not express a preference for more or less frequent imaging. Younger patients and those living further away from the imaging center were more concerned about cost of surveillance. Female patients had higher levels of concern compared to males regarding radiation, IV contrast, and overall levels of concern about surveillance. Higher levels of anxiety were correlated with preference for more frequent imaging (rs = 0.274, p = 0.027) and higher overall level of concern about surveillance (rs = 0.259, p = 0.037). Higher negative appraisal scores were also correlated with higher overall concerns (rs = 0.323; p = 0.012). CONCLUSIONS: Patient perspectives should be considered when developing sarcoma surveillance strategies. Identifying patients with greater anxiety and concerns regarding imaging may create opportunities for improved surveillance practices as well as counseling and survivorship interventions.

Preoperative and Postoperative Patient-Reported Outcome Measurement Information System Scores in Patients Treated for Benign Versus Malignant Soft Tissue Tumors.

BACKGROUND: The Patient-Reported Outcomes Measurement Information System (PROMIS) assesses multiple aspects of patient well-being but has not been thoroughly studied amongst orthopedic oncology patients. QUESTIONS/PURPOSES: How do preoperative/early postoperative PROMIS scores compare in patients with benign versus malignant soft tissue tumors (STTs) for (1) physical function, (2) pain interference, and (3) depression? Are the differences clinically relevant? What other patient/tumor factors impact PROMIS? METHODS: This retrospective cohort study included 314 STT patients who underwent resection of a benign (n = 187) or malignant (n = 127) STT over a period of 4.25 years at a single institution. PROMIS physical function, pain interference, and depression scores were collected preoperatively and at two and six weeks postoperatively. Scores for each time point were compared between groups and to preoperative baselines. Backward-stepwise linear mixed-effects models were produced to identify independent predictors of change in each PROMIS domain. The minimal clinically important difference (MCID) was 4 points. RESULTS: The malignant cohort, but not the benign cohort, demonstrated clinically relevant worsening of physical function postoperatively. Malignant diagnosis (△ = -4.4, p < 0.001) and lower extremity tumors (△ = -4.5, p < 0.001) were identified as clinically relevant, independent predictors of worse physical function at all time points. No predictors of clinically relevant changes in pain interference or depression scores, including malignancy, were identified. CONCLUSIONS: In STT patients, malignancy and lower extremity STT location are associated with clinically relevant worsening in physical function but do not significantly impact pain interference or depression in the early postoperative period. These findings may help establish the utility of PROMIS in an orthopedic oncology population.

Patients With Metastatic Disease Are at Highest Risk for Anxiety and Depression in an Orthopedic Oncology Patient Population.

PURPOSE: Patients with cancer are at risk for anxiety and depression; however, the patterns and predictors of symptoms in an orthopedic oncology population have not been studied. METHODS: We retrospectively reviewed Patient-Reported Outcomes Measurement Information System scores of all adult patients who underwent palliative surgery for metastatic cancer, resection of a sarcoma, or nononcologic total joint arthroplasty at a single institution from 2015 to 2020. Backward stepwise linear regression was used to determine risk factors for perioperative anxiety and depression. RESULTS: Postoperative anxiety and depression were more prevalent in patients with metastatic disease than localized cancer or nononcologic conditions (P < .001 and P < .001, respectively). Worse preoperative pain and function were associated with higher preoperative anxiety (ß = .321, P = .001; ß = -.236, P = .012, respectively) and depression (ß = .245, P = .009; ß = -.279, P = .003, respectively). Worse preoperative anxiety, preoperative depression, and postoperative pain were associated with higher postoperative anxiety (ß = .204, P = .012; ß = .260, P = .001; ß = .447, P < .001, respectively). Worse preoperative depression and postoperative pain also predicted higher postoperative depression (ß = .542, P < .001; ß = .325, P < .001, respectively). CONCLUSION: Anxiety and depression were most prevalent in patients with metastatic disease. Compared with total joint arthroplasty patients, patients with cancer less frequently experienced postoperative improvements in anxiety and depression. Worse preoperative pain and function were independently associated with greater preoperative anxiety and depression. Providers should maintain awareness of the relationship between mental and physical health to optimize outcomes.

Depression Is Transiently Increased in Patients Undergoing Two-Stage Revision Arthroplasty.

BACKGROUND: The implications of two-stage revision on mental health are poorly understood. The purpose of this study is to determine (1) whether patients undergoing two-stage revision total hip and knee arthroplasty for prosthetic joint infection were more likely to get Patient-Reported Outcomes Measurement Information System (PROMIS) Depression scores consistent with major depressive disorder (MDD) than those undergoing aseptic revision and (2) whether these symptoms resolved after the procedure. METHODS: Records of all 366 patients that underwent revision total hip or knee arthroplasty from January 1, 2015, - June 20, 2019, were reviewed. Forty-two patients were excluded for missing PROMIS Depression scores or incomplete treatment. Preoperative (<3 months), early postoperative (2-8 weeks), and final postoperative (6-18 months) Depression scores were collected. Patients crossing the PROMIS Depression threshold equivalent to a Patient Health Questionnaire-9 score ≥10, indicative of MDD, were evaluated. RESULTS: More two-stage revision patients developed Depression scores indicative of MDD perioperatively than the aseptic cohort (20.0% vs 6.5%, P = .01). Two-stage revision patients had higher (worse) median Depression scores preoperatively (54.8 vs 51.3, P = .04) and at early follow-up (54.3 vs 49.9, P = .01), but not at final follow-up (50.4 vs 49.1, P = .39). Across all patients, Depression scores improved by 2.4 points at early follow-up (95% confidence interval:1.1-3.7; P < .001) and 3 points at final follow-up (95% confidence interval:1.5-4.5; P < .001; minimal clinically important difference 3.0). CONCLUSIONS: Twenty percent of two-stage revision arthroplasty patients, compared to <7% of aseptic revision patients, developed PROMIS Depression scores consistent with MDD during treatment. At final follow-up, a clinically significant improvement in Depression scores from baseline was evident in both cohorts.

Patterns of Extrapulmonary Metastases in Sarcoma Surveillance.

Soft tissue sarcomas (STS) most commonly metastasize to the lungs. Current surveillance guidelines variably recommend abdominal and pelvic imaging, but there is little evidence to support this. We sought to determine the proportion of initial pulmonary versus extrapulmonary metastases, the time to development of each, and factors to identify patients that would benefit from abdominopelvic surveillance. We retrospectively reviewed 382 patients who underwent surgical treatment for STS at a single institution. Of the 33% (126/382) of patients who developed metastases, 72% (90/126) were pulmonary, 22% (28/126) were extrapulmonary, and 6% (8/126) developed both simultaneously. Initial extrapulmonary metastases occurred later (log rank p = 0.049), with median 11 months (IQR, 5 to 19) until pulmonary disease and 22 months (IQR, 6 to 45) until extrapulmonary disease. Pulmonary metastases were more common in patients with high grade tumors (p = 0.0201) and larger tumors (p < 0.0001). Our multivariate analysis did not identify any factors associated with initial extrapulmonary metastases. A substantial minority of initial metastases were extrapulmonary; these occurred later and over a broader time range than initial pulmonary metastases. Moreover, extrapulmonary metastases are more difficult to predict than pulmonary metastases, adding to the challenge of creating targeted surveillance protocols.

Does Medical Students' Sense of Belonging Affect Their Interest in Orthopaedic Surgery Careers? A Qualitative Investigation.

BACKGROUND: The concept of social belonging has been shown to be important for retention and student success in collegiate environments and general surgery training. However, this concept has never been explored in relation to medical students' impressions of orthopaedic surgery careers. QUESTION/PURPOSE: To investigate medical students' sense of belonging in orthopaedic surgery and how it affects their interest in pursuing orthopaedic surgery careers. METHODS: Medical students from four medical schools were invited to participate in telephone interviews aimed to investigate medical students' reasons for considering (or not considering) orthopaedic surgery as a future career. Students were selected using random sampling and theoretical sampling methods (selecting participants based on specific characteristics) to obtain a diversity of student perspectives across medical school year, gender, race, age, and interest in orthopaedics. Semistructured interviews with open-ended questions and face validity were used to minimize bias in the interview process. Analysis was performed using grounded theory methodology, a rigorous and well-established method for creating conceptual models based on qualitative data. The result seeks to be a data-driven (as opposed to hypothesis-driven) theory that provides perspective on human behavior. Interviews were conducted until the point of thematic saturation, defined as the point when no new ideas occur in subsequent interviews; this was achieved at 23 students (16 self-identified as women, 12 self-identified as underrepresented minorities). RESULTS: Medical students articulated stereotypes about orthopaedic surgeons, in particular, that they were white, male, and athletic. Students derived their sense of belonging in orthopaedic surgery from how closely their identities aligned with these stereotypes about the field. Students who felt a sense of belonging described themselves as being part of a cultural "in-group," and students who did not feel a sense of belonging felt that they were in a cultural "out-group." Members of the in-group often reported that orthopaedic experiences further reinforced their positive identity alignment, which typically led to increased interest and continued engagement with the field. Conversely, students in the out-group reported that their exposures to orthopaedics further reinforced their lack of identity alignment, and this typically led to decreased interest and engagement. Many students in the out-group reported pursuing other specialties due to a lack of belonging within orthopaedics. CONCLUSION: Students derive their sense of belonging in orthopaedics based on how closely their identity aligns with stereotypes about the field. Importantly, there were gender and racial factors associated with orthopaedic stereotypes, and thus with belonging (self-identifying as the in-group). Moreover, out-group students tended not to choose orthopaedic surgery careers because of a lack of belonging in the specialty. CLINICAL RELEVANCE: With knowledge of the factors that influence students' sense of belonging, academic orthopaedic departments can focus on interventions that may lead to a more diverse pool of medical students interested in orthopaedic surgery. These might include explicitly addressing stereotypes about orthopaedics and cultivating positive identity alignment for students from diverse backgrounds through targeted mentorship fostering partnerships with affinity organizations, and creating space to talk about barriers. Targeted interventions such as these are needed to interrupt the cycle of in-group and out-group formation that, in this small multicenter study, appeared to deter students with underrepresented identities from pursuing orthopaedic surgery careers.

Gender Representation in Speaking Roles at the American Association of Hip and Knee Surgeons Annual Meeting: 2012-2019.

BACKGROUND: The American Association of Hip and Knee Surgeons (AAHKS) has one of the lowest percentages of women members among orthopedic surgery subspecialty societies, having increased from 1.3% to 3.1% since 2012. Our purpose was to report the representation of women in various speaking roles at the AAHKS annual meeting over this time period. METHODS: We accessed the 2012-2019 AAHKS annual meeting programs online and reviewed all paper presenters, symposium faculty, and session moderators. We recorded instances of women speakers and their degree and specialty. We calculated the percentage of women speakers, women orthopedic surgeon speakers, women session moderators, and women symposium faculty for the overall period of 2012-2019, and for each annual meeting. RESULTS: Between 2012 and 2019, 33/877 (3.8%) of all speakers at AAHKS were women. Of these, 21 were women orthopedic surgeons, or 2.4% of all speakers. The proportion of total women speakers per year ranged from 1.7% (2017) to 6.4% (2013). Twenty-four of 492 (4.9%) paper presenters were women, and 12/492(2.4%) were women orthopedic surgeons. Four of 143 (2.8%) session moderators were women, and all were orthopedic surgeons. Five of 245 (2.0%) symposium faculty were women, and 0/245 (0%) were women orthopedic surgeons. CONCLUSION: Although the percentage of women AAHKS members has grown since 2012, the small percentage of women orthopedic surgeons speaking at AAHKS has not. There were no women orthopedic surgeons included on symposium faculty over this entire period. We appreciate and encourage efforts to improve gender diversity among speakers at AAHKS annual meetings.

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.

Vascularized Ulnar Transposition and Radioulnoscapholunate Fusion With Volar Locking Plate in a Dorsal Position Following Resection of Giant Cell Tumor of the Distal Radius.

Giant cell tumor of the distal radius is a rare, locally destructive, and frequently recurrent tumor. We present a case of Campanacci Grade III giant cell tumor of the distal radius with pathologic fracture and cortical destruction which was treated with neoadjuvant denosumab. This facilitated en-bloc resection of the entire distal radius, including the articular surface, while minimizing tumor contamination. Reconstruction was accomplished using a vascularized ulnar transposition flap to facilitate radioulnoscapholunate fusion, which was fixated using a long-stem contralateral variable angle locking volar distal radius plate in a dorsal position. This case illustrates multidisciplinary management of a challenging reconstructive problem and demonstrates a novel strategy for fixation which repurposes familiar and readily available hardware to provide optimal osteosynthesis.

The Impact of COVID-19 on the Orthopaedic Surgery Residency Application Process.

Over recent months, coronavirus disease 2019 (COVID-19) has swept the world as a global pandemic, largely changing the practice of medicine as it was previously known. Physician trainees have not been immune to these changes-uncertainty during this time is undeniable for medical students at all levels of training. Of particular importance is the potential impact of COVID-19 on the upcoming residency application process for rising fourth-year students; a further source of added complexity in light of the newly integrated allopathic and osteopathic match in the 2020 to 2021 cycle. Owing to the impact COVID-19 could have on the residency match, insight regarding inevitable alterations to the application process and how medical students can adapt is in high demand. Furthermore, it is very possible that programs will inquire about how applicants spent their time while not in the hospital because of COVID-19, and applicants should be prepared to provide a meaningful answer. Although competitive at a basal level, the complexity of COVID-19 now presents an unforeseen, superimposed development in the quest to match. In this article, we aim to discuss and provide potential strategies for navigating the impact of COVID-19 on the residency application process for orthopaedic surgery.