Use of problem-based learning in orthopaedics education: a systematic review and meta-analysis of randomized controlled trials.

BACKGROUND: Currently, problem-based learning (PBL) has been widely used in many disciplines, but no systematic review has explored the advantages and disadvantages of PBL in orthopaedics education. METHODS: We searched the PubMed, Cochrane Library, Embase, Web of Science, Scopus, Chongqing VIP Database (VIP), Chinese National Knowledge Infrastructure (CNKI), and Wanfang databases up to April 2023 to identify for relevant studies. Relevant studies were identified by using specific eligibility criteria, and data were extracted. RESULTS: A total of 51 randomized controlled trials with 4268 patients were included. Compared with traditional education, PBL teaching yielded significantly higher knowledge scores (SMD=1.10, 95% CI: 0.78~1.41, P<0.00001), procedural skill scores and clinical skill scores than traditional teaching (SMD=2.07, 95% CI: 1.61~2.53, P<0.00001; SMD=1.20, 95% CI: 0.88~1.52, P<0.00001). Moreover, the total scores were higher in the PBL teaching group than in the traditional teaching group (MD=5.69, 95% CI: 5.11~6.26, P<0.00001). Students also expressed higher levels of interest and satisfaction in the PBL teaching group than in the traditional teaching group (OR=4.70, 95% CI: 3.20~6.93, P<0.00001; OR=5.43, 95% CI: 3.83~7.69, P<0.00001). However, there was less learning time and higher levels of learning pressure in the PBL teaching group (OR=0.12, 95% CI: 0.06~0.24, P<0.00001; OR=5.95, 95% CI: 3.16~11.23, P<0.00001). CONCLUSION: Current evidence indicates that PBL teaching can increase knowledge scores, procedural skill scores, and clinical skill scores. Students have higher levels of interest in teaching and higher levels of teaching satisfaction in the PBL group. However, students can feel higher levels of study pressure and experience less study time. The findings of the current study need to be further verified in multicentre, double-blind and large-sample RCTs.

Factors that influence medical students' decision to pursue a career in orthopaedics: a comprehensive analysis.

PURPOSE: Selecting a postgraduate medical or surgical specialty is a significant decision for medical students, influenced by factors such as demographics, academic performance, satisfaction, work environments, personal aspirations, passion for a specific specialty, exposure to different fields during medical education, lifestyle considerations, financial factors, job market conditions, and prospects. Our research focused on orthopaedic surgery, a highly competitive specialty with many applicants and a low acceptance rate. We aimed to investigate the factors that contribute to the sustained interest in this specialty despite the challenges of securing a residency position. Hence, this study aims to examine the potential factors that influence students' decision to pursue a career as an orthopaedic surgeon. METHODS: This cross-sectional study explores the perspectives and attitudes of 211 fifth-year medical students towards orthopaedic surgery after completing their clinical rotation at Mutah University's School of Medicine in 2022. The inclusion criteria for the study were limited to fifth-year medical students who successfully finished the orthopaedic rotation. A questionnaire was employed to evaluate students' firm commitment to orthopaedics as a prospective career and the degree of their current interest in the specialty. RESULTS: The study involved 210 participants, with 99 selecting orthopaedics as their specialty and 111 pursuing alternatives. Furthermore, 41.4% expressed the intention to apply for orthopaedic residencies. Factors impacting orthopaedics selection included family/peer input (p = 0.002), prestige (p = 0.002), research prospects (p = 0.005), leadership potential (p = 0.011). Chi-square analysis showed associations between choosing orthopaedics and male gender (p = 0.028), parental occupation in musculoskeletal fields (p = 0.038), and elective rotations (p = 0.016). CONCLUSION: This study examines the factors that influence medical students' career preferences in orthopaedic surgery, highlighting the significance of familial and peer influences, job prestige perceptions, gender considerations, parental involvement, elective rotations, research and teaching potential assessments, and aspirations for leadership roles. These findings reveal the complex array of factors that guide medical students toward orthopaedic surgery.

Diversity, Equity, and Inclusion in Orthopaedic Surgery: Local and National Efforts.

Orthopaedic surgery has not experienced the same increase in diversity as other surgical subspecialties over time. Professional orthopaedic societies across the nation, including the American Academy of Orthopaedic Surgeons, are now making sincere efforts to improve diversity, equity, and inclusion (DEI) within the field. Several national groups provide funding to support DEI -related research as well as scholarships to national meetings. Others are more focused on mentorship and mitigation of residency attrition amongst underrepresented minorities (URMs). Individual residency programs, including the Department of Orthopaedics at Brown University, are engaging in community outreach to attract more diverse candidates to orthopaedics and providing away rotation scholarship support for medical students that identify as female or URMs. These local and national efforts will hopefully lead to a more inclusive environment for all trainees and practitioners within orthopaedics and ultimately improved orthopaedic care for all patients.

Mental Skills for Orthopaedic Surgery.

Orthopaedic surgery training focuses primarily on the knowledge base and surgical techniques that comprise the fundamental and physical pillars of performance. It also pays much less attention to the mental pillar of performance than does the training of other specialists such as aviators, elite athletes, musicians, and Special Forces operators. However, mental skills optimize the ability to achieve the ideal state during surgery that includes absolute focus with the right amount of confidence and stress. The path to this state begins before surgery with visualization of the surgical steps and potential complications. On the day of surgery, the use of compartmentalization, performance aspirations, performance breathing, and keeping the team focused facilitates achieving and maintaining the proper mental state. Considering the similarities between surgery and other fields of expertise that do emphasize the mental pillar, including this training in orthopaedic residencies, is likely beneficial.

Trends in ACGME Accreditation of Orthopedic Surgery Fellowship Training.

Currently, most surgeons pursue subspecialty fellowship training. This study answers the following questions: (1) How does the rate of fellowship training in orthopedic surgery compare with that in other surgical specialties? (2) To what extent did adoption of Accreditation Council for Graduate Medical Education (ACGME) accreditation change from 2013 to 2021? Orthopedic subspecialties were analyzed for total number of fellowship programs and positions in the 2013 and 2021 Match. Rates of ACGME accreditation were analyzed via chi-square tests. In 2021, orthopedic surgery had the highest rate of fellowship selection (94%) relative to general surgery (77%), ophthalmology (66%), plastic surgery (63%), and otolaryngology (55%). Across all orthopedic subspecialties, the percentage of ACGME accreditation decreased among fellowship programs (53% in 2013 to 48% in 2021, P=.166) and positions (58% in 2013 to 50% in 2021, P<.001). Orthopedic sports medicine had the highest adoption of ACGME accreditation (100%), followed by hand surgery (99%), musculoskeletal oncology (67%), and pediatric orthopedics (56%). Significant increases in the adoption of ACGME accreditation were noted for orthopedic sports medicine (93% in 2013 to 100% in 2021, P=.016) and hand surgery (81% in 2013 to 99% in 2021, P<.001). There was a significant decrease in ACGME accreditation for adult reconstructive orthopedics (40% in 2013 to 24% in 2021, P=.042), driven by the increase in unaccredited fellowship programs. Accreditation of orthopedic subspecialty fellowship training has decreased with respect to the proportion of accredited training positions. More research is needed to understand the benefits of ACGME accreditation for fellowship training in orthopedic surgery. [Orthopedics. 2024;47(1):57-63.].

Barriers to Entry: Socioeconomic Discrepancies Between Unmatched First-Time Applicants and Reapplicants in the Field of Orthopaedic Surgery.

INTRODUCTION: Orthopaedic surgery remains a competitive surgical subspecialty with more applicants than spots each year. As a result, numerous students fail to match into these competitive positions each year with a growing number of reapplicants in consecutive application cycles. We sought to understand the socioeconomic factors at play between this growing reapplicant pool compared with first-time applicants to better understand potential discrepancies between these groups. Our hypothesis is that reapplicants would have higher socioeconomic status and have less underrepresented minority representation compared with successful first-time applicants. METHODS: A retrospective review of deidentified individual orthopaedic surgery applicant data from the American Association of Medical Colleges was reviewed from 2011 to 2021. Individual demographic and application data as well as self-reported socioeconomic and parental data were analyzed using descriptive and advanced statistics. RESULTS: Of the 12,112 applicants included in this data set, 77% were first-time applicants (61% versus 17% successfully entered into an orthopaedic surgery residency vs versus unmatched, respectively), whereas 22% were reapplicants. In successful first-time applicants, 12% identified as underrepresented minorities in medicine. The proportion of underrepresented minorities was significantly higher among unmatched first-time applicants (20%) and reapplicants (25%) ( P < 0.001). Reapplicants (mean = $83,364) and unmatched first-time applicants (mean = $80,174) had less medical school debt compared with first time applicants (mean = $101,663) ( P < 0.001). More than 21% of reapplicants were found to have parents in healthcare fields, whereas only 16% of successful first-time applicants and 15% of unsuccessful first-applicants had parents in health care ( P < 0.001). CONCLUSIONS: Reapplicants to orthopaedic surgery residency have less educational debt and are more likely to have parental figures in a healthcare field compared with first-time applicants. This suggests the discrepancies in socioeconomic status between reapplicants and first-time applicants and the importance of providing resources for reapplicants.

Opportunities for Increasing Diversity in Orthopaedics Through Virtual Mentorship Programs.

Orthopaedic surgery lags in recruiting women and under-represented minorities (URMs). In addition, women and URMs hold fewer leadership roles across orthopaedic subspecialties. This inequity is geographically heterogeneous, with female URM residents and attendings being more concentrated in some areas of the country. For instance, practicing female orthopaedic surgeons are more prevalent in Northeast and Pacific programs. Mentorship and representation in leadership positions play a notable role in trainee recruitment. Video communication platforms offer a novel mechanism to reach historically under-represented students across the country. We reviewed five established mentorship programs focused on women and URMs. Each program emphasized a longitudinal relationship between mentors and mentees. In reviewing these programs, we sought to identify the successful components of each program. Leveraging and integrating effective components already established by conventional mentorship programs into virtual programming will aid in optimizing those programs and improve geographic equity in access to mentorship resources. It is critical to extend the principles of successful mentorship programs to technology-enabled programs moving forward.

Feasibility of a Novel Fluoroscopic Trainer for the Orthopaedic Trainee.

OBJECTIVE: We sought to create a novel method of teaching orthopedic trainees to efficiently obtain intraoperative radiographs using nonfluoroscopic digital cameras. Specifically, teaching them to make minor, uniplanar, adjustments while limiting the number of fluoroscopy images obtained during placement of a guidewire "start-point," for intramedullary nailing. DESIGN: Prospective cohort study including medical students from 2 academic centers. Two nonfluoroscopic digital cameras simulating orthogonal fluoroscopic images were utilized. A sponge was used to simulate soft tissue resistance while navigating a guidewire to the desired starting point. Three cannulated parallel cylinders in a triangular configuration are used to simulate our "start point." Students completed 4 phases; trial and error, teaching, testing and retention. SETTING: The protocol was completed at a single academic teaching hospital at the primary authors institution. PARTICIPANTS: We utilized medical students from 2 GME accredited medical schools to complete the protocol. Students were selected from orthopedic surgery interest groups at their respective institutions and participation was voluntary. RESULTS: Twenty-one medical students completed the protocol. The number of seconds to achieve each target along with the number of pictures to achieve each target were recorded and averaged. The paired t-test was used to compare the difference between phases. There is a statistically significant difference in the mean number of seconds to achieve each target between phase 1 (baseline) and phase 3 (testing) (p < 0.0001). This statistically significant difference was retained in phase 4 (retention) (p < 0.0001). CONCLUSIONS: We were able to demonstrate a statistically significant decrease in the number of images and time to obtain the correct "start point." This could theoretically decrease operative time and morbidity while teaching students in a low-stress training environment without exposure to radiation.

The Pregnant Arthroplasty Surgeon: A Women in Arthroplasty Committee Editorial.

BACKGROUND: Women orthopaedic surgeons face unique challenges during their careers. There are extremely low numbers of women in the field, particularly in the specialty of adult reconstruction. Factors contributing to low numbers of women entering this subspecialty include increased perceived physical demand relative to other fields, occupational hazards during pregnancy such as exposure to radiation and polymethylmethacrylate bone cement, concerns for work-life balance, and limited number of women within the subspecialty. The following editorial provides a framework to understand and manage the potential occupational hazards to pregnant and lactating surgeons, parental leave, and postpartum return to work. We aim to dispel any unfounded myths and provide evidence-based education that may help overcome these barriers. In doing so, we hope to encourage more women to consider adult reconstruction as a potential career. METHODS: Our primary method consisted of completing an extensive literature review on the past and current articles about the aforementioned barriers which may contribute to the low number of women entering adult reconstruction. After this literature search was completed, we composed a comprehensive editorial that provided evidence-based education and recommendations for medical professionals. CONCLUSIONS: Issues pertaining to parenthood, pregnancy, and lactation pose barriers to success for women in orthopedic surgery. These concerns may dissuade talented women from pursuing a rewarding career in adult reconstruction. Education on these issues is needed to help our early-career colleagues plan and care for their families. Clearly stated and published policies should be made available in all training programs, fellowships, and clinical practices to allow understanding and unbiased implementation. By being more inclusive, adult reconstruction will have access to the best possible surgeons, which will benefit not only patients but the field as a whole.

The Utility of the Standardized Letter of Recommendation for Orthopedic Surgery Residency Applicants: A Systematic Review.

Despite widespread adoption for evaluating residency candidates, few studies have evaluated the orthopedic standardized letter of recommendation (SLOR). A systematic review using PubMed, Embase, and Web of Science was performed in June 2022. Study design and results from SLOR investigations were compiled. Common outcomes studied were summative rank statement scores and SLOR individual domains. Applicants were rated ranked to match or in the top one-third of rank lists in non-normally distributed frequencies. The association of summative rank statement score with match outcome was rarely studied. Applicants' ratings skew positively, the utility is reportedly limited, and influence on match outcome has been inadequately studied. [Orthopedics. 2024;47(1):e1-e5.].

Motivations and Barriers for Women Orthopaedic Surgeons Considering Arthroplasty Fellowship.

BACKGROUND: Arthroplasty is one of the least gender-diverse orthopaedic subspecialties. While previous studies have looked at factors influencing fellowship choices for women, few studies have attempted to understand the decision for or against arthroplasty specifically. Working to better understand fellowship choice is a critical step in the process of increasing women recruitment. METHODS: An anonymous survey was distributed using REDCap to women orthopaedic surgeons and trainees through listservs, social media groups, and residency programs. Surgeons who had decided on a specific subspecialty or already completed fellowship were included. Responses were obtained from 164 surgeons (72 arthroplasty surgeons, 92 other subspecialties). Chi-squared and Fisher's Exact tests were then performed. RESULTS: The most important factor for those who chose arthroplasty was enjoyment of the surgeries. The biggest concerns from those in the arthroplasty group about the field were work-life balance, ability to become pregnant and/or have a healthy pregnancy, and sex bias from referring physicians. Of those who ultimately chose another subspecialty, 30.4% considered arthroplasty "a little" and 8.7% considered it "strongly." The most important dissuaders for the group that considered arthroplasty were concerns about "boy's club" culture, concerns about the physicality of the surgeries, and a lack of mentors. CONCLUSION: While the decision to choose a career path is multifactorial, our hope is that through the identification of modifiable factors we can increase women representation in arthroplasty. Increasing mentorship, implementing practical solutions to improve work-life balance, supporting healthy pregnancies, and mitigating the physical demands of surgery could help address current disparities.

Perceptions of Preference Signaling in Orthopaedic Surgery: A Survey of Applicants and Program Directors.

INTRODUCTION: To improve transparency between candidates and training programs, a preference signaling program (PSP) was implemented before the 2022 to 2023 orthopaedic surgery match. The PSP allows applicants to 'signal' up to 30 programs, informing the program of the applicant's particular interest in interviewing for their available position(s). This study reports the perspectives of orthopaedic surgery residency applicants and program directors (PDs) on the effects of preference signaling on the orthopaedic match. METHODS: Electronic surveys were distributed to PDs and applicants. RESULTS: Almost all programs participated in the PSP (90%), and most of the applicants (97.6%) used 25 to 30 of their allotted preference signals. Most of the applicants (67.2%) thought that their likelihood of obtaining an interview was improved at 'signaled' programs but decreased at programs without a 'signal' designation (85.3%). Both applicants and PDs considered preference signaling to be one of the three most important factors for interview selection, along with Step 2 CK score and letters of recommendation. The applicants did not think that their likelihood of matching would improve with fewer allotted signaling tokens (35.2%), and 55.2% of PDs believed 21 to 30 tokens were optimal. CONCLUSION: Preference signaling is highly regarded by applicants and PDs. Signaling a program will likely improve an applicant's chance to interview. The optimal number of signaling tokens remains unknown, although both groups favored a larger allotment of tokens than has been seen in other specialties. Universal guidelines and recommendations for applicants and PDs would improve the utility of preference signaling.

Nationwide Effect of COVID-19 on Cases Performed During Pediatric Orthopaedic Surgery Fellowship Training in the United States.

INTRODUCTION: The COVID-19 pandemic negatively affected surgical training in the United States. We hypothesized that reported case volume during pediatric orthopaedic surgery fellowship training would decrease markedly during the 2019 to 2020 academic year, which corresponded with the COVID-19 outbreak. METHODS: The Accreditation Council for Graduate Medical Education provided nationwide case logs for accredited pediatric orthopaedic surgery fellows (2017 to 2021). Annual reported case volumes were extracted and summarized as means ± SD. Parametric tests were used to compare annual case volumes. RESULTS: A total of 149 pediatric orthopaedic fellows from 23 accredited fellowships were included. A 16% year-over-year (YoY) decrease was noted in the reported case volume during the 2019 to 2020 academic year (238 ± 80 vs. 255 ± 60, P < 0.001). Nonacute case categories had the most notable YoY percentage decreases: Soft Tissue: Transfer, Lengthen, Release (-42%); Clubfoot (-34%); and Foot and Ankle Deformity (-31%). Acute case categories had the most notable YoY percentage increases: Trauma Lower Limb (12%) and Trauma Upper Limb (10%). A subsequent 42% YoY increase was noted in the reported case volume during the 2020 to 2021 academic year. DISCUSSION: A 16% YoY decrease was noted in the reported case volume during the 2019 to 2020 academic year, which corresponded to widespread economic shutdowns during the initial COVID-19 outbreak. Nonacute cases experienced the greatest negative effect. The results from this study may inform the orthopaedic surgery community on the effect of future national emergencies, such as viral outbreaks.

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

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

Variation in Reported Learning Outcomes and Measurement Instruments in Hip Arthroscopy Simulation Training: A Systematic Review.

PURPOSE: To systematically review the current literature on the effectiveness of hip arthroscopy simulation training and to determine the consistency of reporting and validation of simulation used in hip arthroscopy. METHODS: Three databases (PubMed, EMBase, and CINAHL) were screened using PRISMA guidelines in January 2022 for published literature on virtual simulation in hip arthroscopy. Studies reporting on the use of hip arthroscopy simulation training in orthopedic surgical trainees were included and assessed for quality and risk of bias using MINORS criteria. The number of participants, participant education level, experience, simulator type, validation type, method of assessment, and simulation outcomes were extracted from included studies. RESULTS: Of the 286 articles screened, 11 met inclusion criteria for review evaluating 323 orthopedic trainees with a mean of 29.36 participants per study published between 2012 and 2021, most commonly in the United Kingdom (55%). The four most reported surgical skills evaluated were visualization and probing tasks (82%), mean time to perform the task (73%), number of cartilage and soft tissue collisions (73%), and number of hand movements (73%). The most described measurement instruments included a simulation built-in scoring system (55%), Arthroscopic Surgical Skill Evaluation Tool (ASSET) Global Rating Scale (GRS) (27%), and motion analysis system (18%). Construct validity was the most reported overall type of validity (82%), followed by face validity (36%), transfer validity (18%) and content validity (18%). Construct validity was also the most reported validity for the simulator and measurement instrument (55% and 89%, respectively). CONCLUSIONS: There is significant variation in reported learning outcomes and measurement instruments for evaluating the effectiveness of hip arthroscopic-based education. This study highlights that simulation training may be an effective tool for evaluation of hip arthroscopy skills. LEVEL OF EVIDENCE: Level III, systematic review of level I to III studies.

Training and Evaluation of Residents to Ensure Competent Physician Metrics to Recognize Struggling Residents.

Assessing competency across domains of knowledge, skills, and behavior is critical to ensure that graduating orthopaedic residents possess the requisite skills and attributes to enter independent orthopaedic practice. Of the domains, knowledge is most easily assessed. In addition to the AAOS Orthopaedic In-Training Examination®, which provides a yearly gauge of residents' orthopaedic knowledge relative to their peers, there are several online platforms such as Orthobullets, the American Academy of Orthopaedic Surgeons ResStudy program, and the Journal of Bone and Joint Surgery Clinical Classroom that offer online learning resources and question banks. Clinical skills are best assessed through a combination of observation tools, including live or video assessments, 360° evaluations, and objective structured clinical examinations. Surgical skills can be evaluated in two domains: live surgical cases or simulations. The American Board of Orthopaedic Surgery is attempting to standardize live surgical evaluations through the use of the O-P tool. Although most available models feature only arthroscopic procedures, surgical simulators provide for opportunity to objectively evaluate resident performance. Behavior and professionalism has traditionally been the most challenging domain to assess. The American Board of Orthopaedic Surgery's Behavior Assessment Tool has demonstrated success in pilot testing and is being introduced as the standard for measuring behavior and professionalism in orthopaedic training. Although no single assessment tool can accurately gauge a resident's overall performance, a combination of readily available tools should be used to assess competence across domains.