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Introduction: A pronounced gender imbalance is evident among orthopaedic surgeons. In the field of arthroplasty, there exists a dearth of comprehensive data regarding gender representation. This study aimed to analyze the gender diversity, or lack thereof, within the field of total hip arthroplasty (THA). In addition, this study used literature review to identify possible reasons for the gender disparity among THA surgeons and identify the best next steps to promote gender equity within orthopaedics., Methods: A retrospective analysis was conducted using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set to quantify orthopaedic surgeons who performed primary THA procedures from 2013 to 2020. To assess trends in the number of hip surgeons by sex and the evolving female-to-male ratio, two-sided correlated Mann-Kendall tests were conducted., Results: Overall, 3,853 to 4,550 surgeons billed for primary THA annually. Of this number, an average of 1.7% was female. The mean number of services billed for by male surgeons was 31.62 ± 24.78 per year and by female surgeons was 26.43 ± 19.49 per year. Trend analysis of female-to-male ratio demonstrated an increasing trend of statistical significance ( P = 0.009). The average number of procedures by female surgeons annually remained stable throughout the study, whereas there was a steady increase in that for male surgeons., Conclusion: Results showed a notable and sustained upward trajectory from 2013 to 2020 in the number of female surgeons billing for THA along with the female-to-male ratio. However, female surgeons constitute a mere 2% of surgeons engaging in primary THA billing. Furthermore, the annual average number of THAs conducted by female surgeons exhibited constancy, whereas there was a gradual increase in the median number of annual procedures performed by their male counterparts. Future studies should aim to identify and resolve specific barriers prohibiting female medical students from pursuing and obtaining a career as an orthopaedic THA surgeon., Study Description: Retrospective analysis using the Medicare Provider Utilization and Payment Data: Physician and Other Practitioners data set., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

Purpose: Rheumatologists and orthopedic surgeons frequently collaborate on difficult decisions regarding perioperative management of immunosuppression in rheumatic disease patients, balancing risk of postoperative infection with risk of disease flares. Current evidence-based guidelines pertain specifically to arthroplasty, thus we sought to understand the trends and common practices regarding peri-arthroscopic use of immunosuppression., Methods: Rheumatologists and sports medicine surgeons, from a variety of New York hospitals and serving a broad range of demographics, were surveyed on immunosuppressive medication management in rheumatic disease patients undergoing arthroscopic surgeries. Physicians' preferences were elicited regarding the use of common anti-rheumatic medications with the lower risk meniscectomies and the higher risk anterior cruciate ligament (ACL) reconstructions and allografts. Physicians were asked specifically about peri-arthroscopic use of conventional synthetic diseasemodifying antirheumatic drugs (csDMARDs), biologics, and Janus kinase (JAK) inhibitors., Results: During the survey period, 25 rheumatologists and 19 sports medicine fellowship-trained orthopedic surgeons completed the questionnaire. For lower-risk arthroscopies, rheumatologists favored continuing various csDMARDs (72% to 100%), biologics (50% to 64%) and JAK inhibitors (57%), while a majority of surgeons concurred for all three drug classes (csDMARDs 63%; biologics 53%; and JAK inhibitors 58%). For higher-risk arthroscopies, most rheumatologists preferred that patients continue csDMARDs (63% to 100%) but fewer supported the use of biologics (28% to 39%) or JAK inhibitors (22%). Surgeons were more hesitant to endorse any class of immunosuppressive antirheumatic medications (22% to 27%) around these higher risk surgeries. The rheumatologists were most concerned about surgeries taking place too soon after the last dose of rituximab, recommending these higher risk surgeries not take place for 7.7 ± 8.8 weeks following the last infusion., Conclusion: For lower-risk arthroscopies, most rheumatologists but only about half of orthopedic surgeons preferred patients continuing csDMARDs. Approximately half of both groups preferred patients hold biologics and JAK inhibitors. In more involved arthroscopies, most rheumatologists but few orthopedists supported the continued use of csDMARDs, and the consensus was to hold all other immunosuppression when possible. While the duration medications were held perioperatively were somewhat reflective of the current guidelines for arthroplasty, there is a need for evidencebased guidelines specifically regarding peri-arthroscopy immunosuppression in rheumatic disease patients.

Background: Reducing differences in the gender representation of shoulder arthroplasty surgeons may help optimize patient care. This work aimed to determine (1) the current gender distribution of surgeons performing shoulder arthroplasty, (2) how gender relates to practice patterns among shoulder arthroplasty surgeons, and (3) how gender distribution has been changing over time., Methods: The Medicare Provider Utilization and Payment Data for the years 2012-2020 were used to identify orthopedic surgeons performing anatomic and reverse total shoulder arthroplasty (Current Procedural Terminology code 23472). The data set provides self-reported gender, credentials, National Provider Identifier, annual volume of all procedures (based on Current Procedural Terminology codes) that were performed ≥11 times in the calendar year, and location for all included providers. The data set was linked to the Medicare Physician Compare data set using National Provider Identifiers to determine hospital affiliations, year of medical school graduation, and graduating medical school. All included hospitals were queried to determine academic status (affiliated orthopedic residency or fellowship program). The American Shoulder and Elbow Surgeons (ASES) directory was reviewed to determine the gender breakdown of current members., Results: The number of surgeons performing ≥11 shoulder arthroplasties annually increased from 821 (13 women [1.6%]) in 2012 to 1840 (53 women [2.9%], P = .05) in 2019. One female surgeon ranked in the top 100 surgeons by shoulder arthroplasty volume in 2012 and in 2020. Female surgeons graduated more recently from medical school (mean, 2005) compared with male surgeons (mean, 1997; P < .001). About 10% of female surgeons (10.8%, 12 of 111) and male surgeons (9.1%, 229 of 2528) practiced at hospitals with orthopedic residents (P = .50). Female surgeons performing shoulder arthroplasty were less likely than male surgeons to perform total knee arthroplasty (29.4% vs. 54.1%, P < .001) and total hip arthroplasty (12.6% vs. 34.7%, P < .001). There were 86 female members of ASES (6.7%, 86 of 1275), with a significant difference in the proportion of women in differing membership categories (P = .017)., Discussion and Conclusion: A diverse cohort of high-volume shoulder replacement surgeons is integral to delivering high-quality shoulder arthroplasty. Currently, the proportion of women performing high-volume shoulder replacement in the United States is small, with little improvement in recent years. However, women performing shoulder arthroplasty are younger and are often involved in academic practices, and the membership of ASES is increasingly female. Continued efforts to promote orthopedics-and to mentor female residents and medical students interested in shoulder surgery-may bring real change to the gender differences among shoulder replacement surgeons over the coming years., (Copyright © 2024 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

Background: Despite the heavy demand for and knowledge of the benefits of diversity, there is a persistent lack of racial, ethnic, and gender diversity in orthopaedic surgery. Since the implementation of diversity initiatives, data have shown that general surgery has been one of the top competitive surgical fields and has demonstrated growth in racial, ethnic, and gender diversity, making general surgery a good point of reference and comparison when analyzing racial and ethnic growth in orthopaedic surgery., Questions/purposes: (1) What were the growth rates for Black and Hispanic orthopaedic residency applicants and residents between 2015 and 2022? (2) How did the growth rates of Black and Hispanic individuals in orthopaedic surgery compare with those of general surgery? (3) How did applicant recruitment and resident acceptance differ between Black and Hispanic people in orthopaedic surgery?, Methods: Applicant data were obtained from historical specialty-specific data from the Association of American Medical Colleges Electronic Residency Application Service Statistics database between 2018 and 2022, and resident data were obtained from the Accreditation Council of Graduate Medical Education Data Resource Book between 2015 and 2021. Between 2018 and 2022, the number of residency applicants totaled 216,677, with 17,912 Black residency applicants and 20,413 Hispanic residency applicants. Between 2015 and 2021, the number of active residents totaled 977,877, with 48,600 Black residents and 62,605 Hispanic residents. Because the applicant and resident data do not overlap throughout all years of observation, a sensitivity analysis of overlapping years (between 2018 and 2021) was conducted to ensure observed trends were consistent and valid throughout the study. All datasets obtained were used to establish the different racial and ethnic proportions of Black and Hispanic residency applicants and residents in four nonsurgical primary care specialties and four surgical subspecialties. A reference slope was created using data from the Association of American Medical Colleges and Accreditation Council of Graduate Medical Education to represent the growth rate for total residency applicants and residents, independently, across all residency specialties reported in each database. This slope was used for comparison among the resident and applicant growth rates for all eight selected specialties. Datapoints were placed into a scatterplot with regression lines, using slope equations to depict rate of growth and R 2 values to depict linear fit. Applicant growth corresponded to applicant recruitment and resident growth corresponded to resident acceptance. Chi-square tests were used to compare residents and residency applicants for the Black and Hispanic populations, separately. Two-way analysis of variance with a time-by-specialty interaction term (F-test) was conducted to determine differences between growth slopes., Results: There was no difference in the growth rate of Black orthopaedic surgery applicants between 2018 and 2022, and there was no difference in the growth rate of Hispanic orthopaedic surgery applicants (R 2 = 0.43; p = 0.23 and R 2 = 0.63; p = 0.11, respectively). However, there was a very slight increase in the growth rate of Black orthopaedic surgery residents between 2015 and 2021, and a very slight increase in the growth rate of Hispanic orthopaedic surgery residents (R 2 = 0.73; p = 0.02 and R 2 = 0.79; p = 0.01, respectively). There were no differences in orthopaedic and general surgery rates of growth for Black applicants between 2018 and 2022 (0.004 applicants/year versus -0.001 applicants/year; p = 0.22), and no differences were found in orthopaedic and general surgery rates of growth for Black residents between 2015 and 2021 (0.003 residents/year versus 0.002 residents/year; p = 0.59). Likewise, Hispanic orthopaedic applicant growth rates did not differ between 2018 and 2022 from the rates of general surgery (0.004 applicants/year versus 0.005 applicants/year; p = 0.68), and there were no differences in orthopaedic and general surgery rates of growth for Hispanic residents (0.007 residents/year versus 0.01 residents/year; p = 0.35). Furthermore, growth rate comparisons between Black orthopaedic applicants and residents between 2018 and 2021 showed applicant growth was larger than resident growth, illustrating that the recruitment of Black applicants increased slightly more rapidly than resident acceptance. Growth rate comparisons between Hispanic applicants and residents showed a larger rate of resident growth, illustrating Hispanic resident acceptance increased slightly faster than applicant recruitment during that time., Conclusion: We found low acceptance of Black residents compared with the higher recruitment of Black applicants, as well as overall low proportions of Black and Hispanic applicants and residents. Future studies might explore the factors contributing to the higher acceptances of Hispanic orthopaedic residents than Black orthopaedic residents., Clinical Relevance: We recommend that more emphasis should be placed on increasing Black and Hispanic representation at the department level to ensure cultural considerations remain at the forefront of applicant recruitment. Internal or external reviews of residency selection processes should be considered, and more immersive, longitudinal orthopaedic surgery clerkships and research mentorship experiences should be targeted toward Black and Hispanic students. Holistic reviews of applications and selection processes should be implemented to produce an increased racially and ethnically diverse applicant pool and a diverse residency work force, and implicit bias training should be implemented to address potential biases and diversity barriers that are present in residency programs and leadership., Competing Interests: Each author certifies that there are no funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article related to the author or any immediate family members. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2024 by the Association of Bone and Joint Surgeons.)

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., (Copyright © 2024 by the American Academy of Orthopaedic Surgeons.)

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., Competing Interests: Disclosure: The Disclosure of Potential Conflicts of Interest forms are provided with the online version of the article (http://links.lww.com/JBJS/G720)., (Copyright © 2021 by The Journal of Bone and Joint Surgery, Incorporated.)

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 χ 2 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., (Copyright © 2020 Society for Vascular Surgery. Published by Elsevier Inc. All rights reserved.)

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., Competing Interests: All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2021 by the Association of Bone and Joint Surgeons.)

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.

Competing Interests: POTENTIAL CONFLICT OF INTEREST: The authors have indicated they have no potential conflicts of interest to disclose.

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., Competing Interests: Each author certifies that neither he, nor any member of his immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2020 by the Association of Bone and Joint Surgeons.)

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., Competing Interests: Each author certifies that neither he nor she, nor any members of his or her immediate family, has funding or commercial associations (consultancies, stock ownership, equity interest, patent/licensing arrangements, etc.) that might pose a conflict of interest in connection with the submitted article. All ICMJE Conflict of Interest Forms for authors and Clinical Orthopaedics and Related Research® editors and board members are on file with the publication and can be viewed on request., (Copyright © 2020 by the Association of Bone and Joint Surgeons.)

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.

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., (Copyright © 2020 Elsevier Inc. All rights reserved.)

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., (Copyright © 2020 Journal of Shoulder and Elbow Surgery Board of Trustees. Published by Elsevier Inc. All rights reserved.)

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.

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.

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.

Background: The gender gap among authors publishing research in journals is narrowing in general medicine and various medical and surgical subspecialties. However, little is known regarding the gender gap among authors publishing research in orthopaedic journals., Questions/purposes: (1) What is the proportion of women first and last authors of original research articles in three high-impact orthopaedic journals from 2006 to 2017? (2) What is the proportion women first authors of original research by orthopaedic subspecialty from 2006 to 2017?, Methods: A sample of original research publications from the even numbered months of issues of Clinical Orthopaedics and Related Research® (CORR®), the Journal of Bone and Joint Surgery, American volume (JBJS), and the American Journal of Sports Medicine (AJSM) were examined from 2006 to 2017. These journals were selected because of their clinical relevance, target audience, and relatively high impact factors. Over the studied period, a single author extracted and reviewed pertinent data, including the gender of the first and last authors and the primary subspecialty of the research article. The senior author refereed disputes regarding the primary subspecialty of each included article. The proportion of women first and last authors in each journal was compared between 2006 to 2017 using chi-square analysis. The proportion of women first authors according to orthopaedic subspecialty in which an article primarily focused its study was also compared between 2006 to 2017 using chi-square analysis., Results: Data were collected from 6292 articles, 13% (800) of which were first-authored by women and 10% (604) of which were last-authored by women. From 2006 to 2017, the overall percentage of women first authors in the examined journals increased (from 11% in 2006 to 17% in 2017; odds ratio 1.6563 [95 % CI 1.4945 to 1.8356]; p < 0.001). Overall across the period studied, the percentage of women first authors in JBJS was 14% while 12% of first authors in CORR and AJSM were women. Regarding subspecialty, the percentage of women first authorship ranged from 9% in the shoulder subspecialty to 21% in pediatric orthopaedics across all three journals., Conclusions: There has been an increase in the percentage of women first authors in articles published in three high-impact orthopaedic journals from 2006 to 2017. This observed increase is encouraging in terms of promoting gender diversity in orthopaedics and may be reflective of a modest increase in the number of women entering the orthopaedic workforce., Clinical Relevance: Between 2006 and 2017, the overall number of women first authors in CORR, JBJS, and AJSM modestly increased. This may suggest a nascent narrowing of the gender gap in orthopaedics. Although this is a welcome finding in terms of promoting and encouraging gender diversity in this man-dominated field, the overall percentage of women authorship remains modest, at best. Future investigations should examine whether the modest increase in women first authorship over time found in this study translates into an increased percentage of senior/last authorship in the future, as this may have implications for women orthopaedic workforce retention.

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.

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.

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., (Copyright © 2019 The Japanese Orthopaedic Association. Published by Elsevier B.V. All rights reserved.)

Background: Most guidelines recommend both pelvic packing (PP) and angioembolization for hemodynamically unstable pelvic fractures, however their sequence varies. Some argue to use PP first because orthopaedic surgeons are more available than interventional radiologists; however, there is no data confirming this., Methods: This cross-sectional survey of 158 trauma medical directors at US Level I trauma centers collected the availability of orthopaedic surgeons and interventional radiologists, the number of orthopaedic trauma surgeons trained to manage pelvic fractures, and priority treatment sequence for hemodynamically unstable pelvic fractures. The study objective was to compare the availability of orthopaedic surgeons to interventional radiologists and describe how the availability of orthopaedic surgeons and interventional radiologists affects the treatment sequence for hemodynamically unstable pelvic fractures. Fisher's exact, chi-squared, and Kruskal-Wallis tests were used, alpha = 0.05., Results: The response rate was 25% (40/158). Orthopaedic surgeons (86%) were on-site more often than interventional radiologists (54%), p = 0.003. Orthopaedic surgeons were faster to arrive 39% of the time, and interventional radiologists were faster to arrive 6% of the time. There was a higher proportion of participants who prioritized PP before angioembolization at centers with above the average number (> 3) of orthopaedic trauma surgeons trained to manage pelvic fractures, as among centers with equal to or below average, p = 0.02. Arrival times for orthopaedic surgeons did not significantly predict prioritization of angioembolization or PP., Conclusions: Our results provide evidence that orthopaedic surgeons typically are more available than interventional radiologists but contrary to anecdotal evidence most participants used angioembolization first. Familiarity with the availability of orthopaedic surgeons and interventional radiologists may contribute to individual trauma center's treatment sequence.

Study Design: A retrospective review of prospectively collected data., Objective: Our purpose was to evaluate the volume of pediatric spine cases being done by surgeons applying for American Board of Orthopaedic Surgeons (ABOS) certification., Summary of Background Data: Pediatric orthopedic surgery has become increasingly subspecialized over the past decade., Methods: Data were reviewed from the ABOS for surgeons undergoing part II of ABOS certification between 2004 and 2014. Applicants were divided into pediatric orthopedic surgeons and spine surgeons based on their self-declared subspecialty for the ABOS Part II examination. A total of 102,424 cases were reviewed to identify spine cases performed on patients <18 years old., Results: Between 2004 and 2014, the total number of ABOS part II pediatric candidates increased significantly, from a low of 15 to a high of 44 (r = 0.68, P = 0.001). During this time frame, there has been no significant increase in the total number of pediatric spine cases reported (r = 0.09, P = 0.19). In 2004, 46.5% (33/71) of the pediatric spine cases were done by spine surgeons, which decreased to 17.3% (28/162) in 2014. Conversely in 2004, 53.5% (38/71) of pediatric spine cases were done by pediatric orthopedists, which increased to 82.7% (134/162) in 2014. The number of pediatric candidates performing pediatric spine cases decreased 35% from 2004 to 2014, but the percentage performing >20 spine cases during their candidate year has increased from 0% to 7% (r = 0.31, P = 0.04)., Conclusion: The share of pediatric spine surgeries performed by pediatric candidates has increased from 54% in 2004 to 83%, with a corresponding fall in the share surgeries performed by spine candidates (47% to >17%). The percentage of pediatric candidates performing more than 20 spine cases/year increased from 0% to 7%, reflecting a trend of spine subspecialization within pediatric surgery., Level of Evidence: 3.

Background: It is currently unknown to what extent routine histological examination of joint arthroplasty specimens occurs across hospitals nationwide. Although this practice is neither supported nor refuted by the available evidence, given the increasing demand for joint arthroplasties, it is crucial to study overall utilization as well as its main drivers., Questions/purposes: Using national data on joint replacements, we aimed to evaluate: (1) What is the current use of routine histological examination of joint arthroplasty specimens? (2) Does the use vary by geographic location and hospital characteristics? (3) Has use changed over time?, Methods: From the Premier Healthcare database (2006-2016) we included claims data from 87,667 shoulder (595 hospitals, median age 70 years, 16% nonwhite), 564,577 hip (629 hospitals, median age 65 years, 21% nonwhite), and 1,131,323 (630 hospitals, median age 66 years, 24% nonwhite) knee arthroplasties (all elective). Our study group has extensive experience with this data set, which contains information on 20% to 25% of all US hospitalizations. Included hospitals are mainly concentrated in the South (approximately 40%) with equal distributions among the Northeast, West, and Midwest (approximately 20% each). Moreover, the Premier data set has detailed billing information, which allows for evaluations of real-world clinical practice. There was no missing information on the main variables of interest for this specific study. We assessed frequency of histology examination (defined by Current Procedural Terminology codes) overall as well as by hospital characteristics (urban/rural, bed size, teaching status, arthroplasty volume), geographic region (Northeast, South, Midwest, West), and year. Given the large sample size, instead of p values, standardized differences were applied in assessing group differences where a standardized difference of > 0.1 (or 10%) was assumed to represent a meaningful difference between groups. For significance of trends, p values were applied. Percentages provided represent proportions of individual procedures., Results: In most hospitals, histology testing was either rare (1%-10%, used in 187 of 595, 189 of 629, and 254 of 630 hospitals) or ubiquitous (91%-100%, used in 121 of 595, 220 of 629, and 195 of 630 hospitals) for shoulder, hip, and knee arthroplasties, respectively. Overall, histology testing occurred more often in smaller hospitals (37%-53% compared with 26%-45% in larger hospitals) and those located in the Northeast (59%-68% compared with 22%-44% in other regions) and urban areas (32%-49% compared with 20%-31% in rural areas), all with standardized differences > 10%. Histologic examination is slowly decreasing over time: from 2006 to 2016, it decreased from 34% to 30% for shoulder arthroplasty, from 50% to 45% for THAs, and from 43% to 38% for TKAs (all p < 0.001)., Conclusions: Although overall use is decreasing, a substantial number of hospitals still routinely perform histology testing of arthroplasty specimens. Moreover, variation between regions and hospital types suggests that this practice is driven by a variety of factors. This is the first study addressing national utilization, which will be helpful for individual hospitals to assess how they compare with national utilization patterns. Moreover, the findings have clear implications for followup studies, which may be necessary given the exponentially growing demand for arthroplasties., Level of Evidence: Level III, therapeutic study.

Orthopedic surgeons frequently encounter medical malpractice claims. The purpose of this study was to assess trends and risk factors in lawsuits brought against orthopedic surgeons using a national legal database. A legal research service was used to search publicly available settlement and verdict reports between 1988 and 2013 by terms "orthopaedic or orthopedic" and "malpractice." Temporal trends were evaluated, and logistic regression was used to identify independent risk factors for case outcomes. A total of 1562 publicly reported malpractice cases brought against orthopedic surgeons, proceeding to trial during a 26-year period, were analyzed. The plaintiffs won 462 (30%) cases, with a mean award of $1.4 million. The frequency of litigation and pay-outs for plaintiffs increased 215% and 280%, respectively, between the first and last 5-year periods. The mean payout for plaintiff-favorable verdicts was highest in pediatrics ($2.6 million), followed by spine ($1.7 million) and oncology ($1.6 million). Fracture fixation (363 cases), arthroplasty (290 cases), and spine (231 cases) were the most commonly litigated procedures, while plaintiffs were most successful for fasciotomy (48%), infection-treating procedures (43%), and carpal tunnel release (37%). When analyzing data by state and region, adjusted for population, northeastern states had a higher frequency of lawsuits. Malpractice liability has increased during the past 3 decades while orthopedic surgeons continue to win most of the cases making it to court. As patients search for medical care via publicly available information, it is important for orthopedic surgeons to understand what aspects of their own practice carry different risks of litigation. [Orthopedics. 2019; 42(2):e260-e267.]., (Copyright 2019, SLACK Incorporated.)

Background: It is generally accepted that all arthroplasty patients should receive venous thromboembolism (VTE) and bleeding risk assessments, and that postoperative thromboprophylaxis be routinely prescribed where appropriate. Guideline recommendations regarding what to prescribe, however, have been inconsistent over the years, particularly regarding the appropriateness of aspirin. Our aim was to explore thromboprophylaxis patterns in use following hip and knee arthroplasty in Australia, and to examine associated variables., Methods: Orthopaedic surgeons were invited via mail to participate in two national surveys, conducted in 2012 (N = 478) and 2017 (N = 820), respectively., Results: The final response rates were 50.0 and 65.8% for 2012 and 2017, respectively. The thromboprophylaxis prescribing routines reported by respondents were divided into four categories: anticoagulant-only (the same anticoagulant-only routine for everyone), aspirin-only (aspirin for everyone), staged-supply (an anticoagulant during the initial postoperative period, followed by aspirin, for everyone) and risk-stratification routines (differing regimens depending on patients' perceived risk of VTE). The most common approaches reported were anticoagulant-only routines; however, their popularity almost halved within the five-year period (from ~ 74% to ~ 41%). Conversely, staged-supply and risk-stratification protocol usage increased by more than two and nine times, respectively. In 2017, over one-half of surgeons reported prescribing aspirin in their practice. Reported concern for postoperative VTE and infections (OR 0.555 95% CI 0.396-0.779, p = 0.001 and OR 1.455 95% CI 1.010-2.097, p = 0.044 respectively), as well as Arthroplasty Society membership (OR 2.814 95% CI 1.367-5.790, p = 0.005) were predictors for use of aspirin (Cox and Snell R square = 0.072). The factor most commonly reported to shape surgeons' protocols was research literature. Factors limiting prescribing of pharmacological prophylaxis included a perception that it increases bleeding and wound infection risk, is inconvenient, and lacks evidence applicable to real-world practice., Conclusions: VTE prevention post-arthroplasty is an evolving and multi-faceted entity, influenced by a range of factors and seemingly in need of robust evidence from large clinical trials to guide practice. The data highlighted potential short-falls in practice related to aspirin over-use, which could be further explored and addressed in future studies in order to optimise patient outcomes and reduce the significant morbidity and healthcare costs associated with VTE following these increasingly common surgical procedures.

Objectives: To (1) define a single institution's rate of open reduction for operative pediatric supracondylar humerus (SCH) fractures; (2) describe variability by surgeon in rates of irreducible fracture (IRF) and open reduction; and (3) determine whether variation in opening rate correlated with surgeon experience., Design: Retrospective analytic study., Setting: Urban tertiary care Level 1 trauma center., Patients/participants: Twelve fellowship-trained pediatric orthopaedists., Main Outcome Measurements: Rate of open reduction for operatively treated SCH fractures (OTA/AO 13-M/3)., Results: One thousand two hundred twenty-nine type II SCH fractures (none of which required open reduction) were excluded from the analysis. A total of 1365 other SCH fractures were included: 1302 type III fractures, 27 type IV fractures, and 36 fractures with unspecified type. 2.9% of type III and 22.2% of type IV fractures required open reduction. None of the injuries with unspecified type required open reduction. The rate of open reduction among 11 surgeons ranged from 0% to 15.0% in type III-IV fractures (P = 0.001). 86% (38/44) of open reductions were performed for IRF. In regression analysis, patient age was associated with open reduction for IRF (odds ratio 1.22, P = 0.001), but surgeon years-in-practice (0.321) and number of previous cases (0.327) were not associated with open reduction. Other indications for opening included suspected vascular or neurologic injury., Conclusions: Open reduction was rarely performed in this sample, but IRF was the dominant indication for opening. We found true variation in surgeons' rates of performing open reductions. More experience was not correlated with decreased likelihood of open reduction., Level of Evidence: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Background: In an era of increasing healthcare costs, the number and value of nonclinical workers, especially hospital management, has come under increased study. Compensation of hospital executives, especially at major nonprofit medical centers, and the "wage gap" with physicians and clinical staff has been highlighted in the national news. To our knowledge, a systematic analysis of this wage gap and its importance has not been investigated., Questions/purposes: (1) How do wage trends compare between physicians and executives at major nonprofit medical centers? (2) What are the national trends in the wages and the number of nonclinical workers in the healthcare industry? (3) What do nonclinical workers contribute to the growth in national cost of healthcare wages? (4) How much do wages contribute to the growth of national healthcare costs? (5) What are the trends in healthcare utilization?, Methods: We identified chief executive officer (CEO) compensation and chief financial officer (CFO) compensation at 22 major US nonprofit medical centers, which were selected from the US News & World Report 2016-2017 Hospital Honor Roll list and four health systems with notable orthopaedic departments, using publicly available Internal Revenue Service 990 forms for the years 2005, 2010, and 2015. Trends in executive compensation over time were assessed using Pearson product-moment correlation tests. As institution-specific compensation data is not available, national mean compensation of orthopaedic surgeons, pediatricians, and registered nurses was used as a surrogate. We chose orthopaedic surgeons and pediatricians for analysis because they represent the two ends of the physician-compensation spectrum. US healthcare industry worker numbers and wages from 2005 to 2015 were obtained from the Bureau of Labor Statistics and used to calculate the national cost of healthcare wages. Healthcare utilization trends were assessed using data from the Agency for Healthcare Quality and Research, the National Ambulatory Medical Care Survey, and the National Hospital Ambulatory Medical Care Survey. All data were adjusted for inflation based on 2015 Consumer Price Index., Results: From 2005 to 2015, the mean major nonprofit medical center CEO compensation increased from USD 1.6 ± 0.9 million to USD 3.1 ± 1.7 million, or a 93% increase (R = 0.112; p = 0.009). The wage gap increased from 3:1 to 5:1 with orthopaedic surgeons, from 7:1 to 12:1 with pediatricians, and from 23:1 to 44:1 with registered nurses. We saw a similar wage-gap trend in CFO compensation. From 2005 to 2015, mean healthcare worker wages increased 8%. Management worker wages increased 14%, nonclinical worker wages increased 7%, and physician salaries increased 10%. The number of healthcare workers rose 20%, from 13 million to 15 million. Management workers accounted for 3% of this growth, nonclinical workers accounted for 27%, and physicians accounted for 5% of the growth. From 2005 to 2015, the national cost-burden of healthcare worker wages grew from USD 663 billion to USD 865 billion (a 30% increase). Nonclinical workers accounted for 27% of this growth, management workers accounted for 7%, and physicians accounted for 18%. In 2015, there were 10 nonclinical workers for every one physician. The cost of healthcare worker wages accounted for 27% of the growth in national healthcare expenditures. From 2005 to 2015, the number of inpatient stays decreased from 38 million to 36 million (a 5% decrease), the number of physician office visits increased from 964 million to 991 million (a 3% increase), and the number of emergency department visits increased from 115 million to 137 million (a 19% increase)., Conclusions: There is a fast-rising wage gap between the top executives of major nonprofit centers and physicians that reflects the substantial, and growing, cost of nonclinical worker wages to the US healthcare system. However, there does not appear to be a proportionate increase in healthcare utilization. These findings suggest a growing, substantial burden of nonclinical tasks in healthcare. Methods to reduce nonclinical work in healthcare may result in important cost-savings., Level of Evidence Level: IV, economic and decision analysis.

Background: American medical schools have gradually achieved balance in the sex of medical graduates over the past 4 decades. However, orthopaedic surgery has remained disproportionately male-dominated. Our aim was to quantify this discrepancy across surgical specialties at the residency training and academic faculty levels. We additionally sought to evaluate the prevalence of women in orthopaedic subspecialty and research societies., Methods: Publicly available data from the Association of American Medical Colleges (AAMC) and the Accreditation Council for Graduate Medical Education (ACGME) for the 2005-2006 to 2016-2017 academic years were pooled for analysis of sex in surgical residency programs. The AAMC 2016 Faculty Roster provided data on the sex composition of academic medical faculty, including rank. Current subspecialty and research society membership demographic characteristics were obtained by directly contacting each group., Results: Female orthopaedic surgery residents represented 0.92% of all female medical residents in the 2016-2017 academic year. Orthopaedic surgery remains the medical specialty with the lowest proportion of female residents at 14.0% in the 2016-2017 academic year, up from 11.0% in the 2005-2006 academic year. The percentage increase over this time period (27.3%) lags behind other male-dominated fields such as neurological surgery (56.8%) and thoracic surgery (111.2%). Women account for 17.8% of full-time orthopaedic surgery faculty at American medical schools, lower than all other medical specialties. In the 2015-2016 academic year, 1 orthopaedic surgery department chair and only 8.7% of professors of orthopaedic surgery were female. Women make up 6.5% of the American Academy of Orthopaedic Surgeons (AAOS) membership. The specialty societies with the fewest women are The Knee Society (0.5%), The Hip Society (0.6%), and the Cervical Spine Research Society (1.5%)., Conclusions: Orthopaedic surgery's slow increase in the number of female residents and academic faculty lags behind that of other specialties. The lack of female orthopaedic surgeons in higher ranks within medical schools is detrimental to recruitment of female medical students to the field. Further efforts should be made toward increasing medical student exposure to orthopaedics and to female mentors in an effort to ensure that the field continues to attract the nation's top medical graduates.

Background: Since the start of the conflict in the Middle East in 2001, military orthopedic surgeons have faced complex orthopedic injuries including high-energy soft tissue wounds, traumatic amputations, and open fractures. Although orthopedic surgeons are well trained in the management of osseous injuries, the treatment of soft tissue injuries can be technically challenging and unfamiliar. Early washout, debridement of devitalized tissue, external fixation of bony injuries, and antibiotic therapy remain the foundation of early wound management. However, these unique extremity injuries have no standard plan of care, and definitive treatment options continue to evolve. The following report highlights the typical cases seen in the wartime setting and offers possible solutions for the associated soft tissue injuries., Methods: A single orthopedic surgeon at a Role 3 combat support hospital performed all cases in this series. This study is a report of the cases that the orthopedic surgeon encountered while deployed and the various techniques that can be used to manage the complex wounds seen in a deployed setting., Findings: Twelve patients were included in this report and the data are shown. Of the 12 patients, 6 were injured by an improvised explosive device (IED), 4 were injured by a high-velocity gunshot wound (HVGSW), 1 was injured by a gunshot wound (GSW), and 1 was injured in an auto versus pedestrian motor vehicle crash. The wound sizes ranged from 10 to 300 cm2. All patients required more than one irrigation and debridement before wound closure. There was a successful outcome in 11 of the 12 patients. The only patient without a known successful outcome was lost to follow up. Six patients were treated with split thickness skin graft (STSG) alone. Four patients were treated with STSG plus an additional means of coverage. One patient was treated with a random flap and one patient was treated with a full thickness skin graft. Integra was used in two of the patients. Each of the patients in whom integra was used had exposed bone and had a successful outcome with respect to tissue coverage., Discussion: This study details different soft tissue coverage techniques that must be learned and possibly employed by the deployed surgeon. Limitations of this study include its retrospective nature and the selected sampling of cases. At initial presentation, the management of war wounds secondary to high-velocity gunshot wounds and improvised explosive devices can be quite daunting. Adhering to firm surgical principles of thorough and meticulous debridement is the foundation of later soft tissue reconstructive options. Once the tissue is deemed clear of infection and contamination, there are myriad treatment options utilizing flaps, synthetic materials, and skin grafting. These are relatively straightforward techniques that the general orthopedic surgeon can utilize while deployed in a combat setting. In the end, it is critical for deployed surgeons to learn multiple techniques to provide definitive soft tissue coverage in a wartime theater., (© Association of Military Surgeons of the United States 2018. All rights reserved. For permissions, please e-mail: journals.permissions@oup.com.)

Study Design: A retrospective review., Objective: This study aimed to determine the factors associated with malpractice litigation in cases involving spine surgery in the United States., Summary of Background Data: Medical malpractice is of substantial interest to the medical community due to concerns of increased health care costs and medical decision-making for the sole purpose of reducing legal liability., Methods: The Westlaw online legal database (Thomson Reuters, New York, NY) was searched for verdict and settlement reports pertaining to spine surgery from 2010 to 2015. Data were collected regarding type of procedure, patient age and gender, defendant specialty, outcome, award, alleged cause of malpractice, and factors involved in the plaintiff's decision to file. Initial search queried 187 cases, after which exclusion criteria were applied to eliminate duplicates and cases unrelated to spine surgery, yielding a total of 98 cases for analysis., Results: The verdict was in favor of the defendant in 62 cases (63.3%). Neurosurgeons and orthopedic surgeons were the most common defendants in 29 (17.3%) and 40 (23.8%) of the cases, respectively. A perceived lack of informed consent was noted as a factor in 24 (24.4%) of the cases. A failure to diagnose or a failure to treat was noted in 31 (31.6%) and 32 (32.7%) cases, respectively. Median payments for plaintiff verdicts were nearly double those of settlements ($2,525,000 vs. $1,300,000). A greater incidence of plaintiff verdicts was noted in cases in which a failure to treat (P < 0.05) was cited, a patient death occurred (P < 0.05), or an emergent surgery had been performed (P < 0.01)., Conclusion: Overall, physicians were not found liable in the majority of spine surgery malpractice cases queried., Level of Evidence: 4.

Aim: To investigate whether the current, generally accepted practice of orthopaedic surgical skills training can raise the performance of supervised residents to levels equal to those of experienced orthopaedic surgeons when it comes to clinical outcomes or implant position after total knee arthroplasty., Methods: In a retrospective analysis of primary total knee arthroplasty outcomes (minimum follow-up of 12 months) procedures were split into two groups: supervised orthopaedic residents as first surgeon (group R), and experienced senior orthopaedic surgeons as first surgeon (group S). Outcome data that were compared 1 year postoperatively were operation times, complications, revisions, Knee Society Scores (KSS) and radiological implant positions., Results: Of 642 included procedures, 220 were assigned to group R and 422 to group S. No statistically significant differences between the two groups were found in patient demographics. Operation time differed significantly (group R: 81.3 min vs. group S: 71.3 min (p = 0.000)). No statistically significant differences were found for complications (p = 0.659), revision rate (p = 0.722), femoral angle (p = 0.871), tibial angle (p = 0.804), femoral slope (p = 0.779), tibial slope (p = 0.765) and KSS (p = 0.148)., Discussion and Conclusion: Supervised residents needed 10 minutes extra operation time, but they provided the same quality of care in primary total knee arthroplasty as experienced orthopaedic surgeons concerning complication rates, revisions, implant position on radiographs and KSS. The currently used training procedure in which the supervising surgeon and the resident decide if the resident is ready to be first surgeon is safe for patients.

Orthopedic surgeons have become increasingly subspecialized, and recent studies have shown that American Board of Orthopaedic Surgery (ABOS) Step II applicants are performing a higher percentage of their cases within their chosen subspecialties. However, these studies focused exclusively on surgeons who have completed a single fellowship; little data exist on those who pursue a second fellowship. All applicants to the ABOS Part II examination from 2004 to 2016 were classified by their self-reported fellowship training history using the ABOS Part II examination database. Trends in the number of applicants completing multiple fellowships and the types of fellowships combined were analyzed. In addition, cases performed by applicants who had performed multiple fellowships were analyzed to determine what percentage were within their chosen subspecialties. A total of 9776 applicants to ABOS Part II were included in the database from 2004 to 2016, including 444 (4.5%) applicants who completed more than one fellowship. There were 43 different combinations of fellowships; the most common additional fellowships were trauma (40.1%), sports medicine (38.7%), and joints (30.4%). The most common combinations were joints and sports medicine (10.6%) and foot and ankle and sports medicine (10.1%). A significant increase occurred in physicians training in both pediatric orthopedics and sports medicine (P=.02). The percentage of cases within the applicants' chosen specialties ranged from 91.4% in sports to 73.6% in tumor. Multiple fellowship applicants represent a small percentage of all applicants, and although subspecialization in orthopedics is increasing, no increasing trend toward multiple fellowships within this dataset was observed. However, the significant increase in applicants who combined pediatric orthopedic and sports medicine fellowships suggests an increasing interest in treating this increasing patient population in addition to social and economic factors. [Orthopedics. 2018; 41(1):e33-e37.]., (Copyright 2017, SLACK Incorporated.)

Objective: To evaluate the change in incidence rate of shoulder arthroplasty, the utilization of shoulder arthroplasty for specific indications, and the surgeon volume trends associated with these procedures between 2005 and 2013., Methods: A population-based cohort study was conducted using the more than 7 million members of an integrated health care system in California. Cases of shoulder arthroplasties performed between 2005 and 2013 were identified using a shoulder arthroplasty registry. Annual shoulder arthroplasty incidence rates per 100,000 patients were determined, and adjusted yearly changes in rates were estimated using incidence rate ratios (IRRs). Changes in surgeon volumes by year and number of surgeons performing different procedures were also compared., Results: The incidence of shoulder arthroplasty per 100,000 members increased from 6.1 (95% confidence interval [95% CI] 5.5-6.7) in 2005 to 13.4 (95% CI 12.5-14.2) in 2013. In patients with osteoarthritis, there was increasing utilization of total shoulder arthroplasty (IRR 1.12 [95% CI 1.11-1.14]) and decreasing utilization of hemiarthroplasty (IRR 0.91 [95% CI 0.89-0.94]). For patients with rotator cuff tear arthropathy, there was an increase in utilization of reverse total shoulder arthroplasty (IRR 1.33 [95% CI 1.29-1.37]) but no change in hemiarthroplasty (IRR 0.99 [95% CI 0.92-1.05]). The average surgeon yearly volume increased for total shoulder arthroplasty (P < 0.001) and for reverse total shoulder arthroplasty (P = 0.020)., Conclusion: Shoulder arthroplasty is being used with greater frequency in this population. Surgeons are performing a greater yearly volume of total shoulder arthroplasty and reverse total shoulder arthroplasty., (© 2016, American College of Rheumatology.)

Objectives: to describe the increase in orthogeriatrician involvement in hip fracture care in England and its association with improvements in time to surgery and mortality., Study Design: analysis of Hospital Episode Statistics for 196,401 patients presenting with hip fracture to 150 hospitals in England between 1 April 2010 and 28 February 2014, combined with data on orthogeriatrician hours from a national organisational survey., Methods: we examined changes in the average number of hours worked by orthogeriatricians in orthopaedic departments per patient with hip fracture, and their potential effect on mortality within 30 days of presentation. The role of prompt surgery (on day of or day after presentation) was explored as a potential confounding factor. Associations were assessed using conditional Poisson regression models with adjustment for patients' sex, age and comorbidity and year, with hospitals treated as fixed effects., Results: between 2010 and 2013, there was an increase of 2.5 hours per patient in the median number of hours worked by orthogeriatricians-from 1.5 to 4.0 hours. An increase of 2.5 hours per patient was associated with a relative reduction in mortality of 3.4% (95% confidence interval 0.9% to 5.9%, P = 0.01). This corresponds to an absolute reduction of approximately 0.3%. Higher numbers of orthogeriatrician hours were associated with higher rates of prompt surgery, but were independently associated with lower mortality., Conclusion: in the context of initiatives to improve hip fracture care, we identified statistically significant and robust associations between increased orthogeriatrician hours per patient and reduced 30-day mortality., (© Crown copyright 2016)

Introduction: Ulnar collateral ligament (UCL) reconstructions are being performed with an increasing annual incidence. The purpose of this study was to evaluate trends in UCL surgery among recently trained orthopaedic surgeons., Methods: The American Board of Orthopaedic Surgeons (ABOS) database was used to identify all UCL reconstructions from 2004 to 2013. Procedures were identified by Current Procedural Terminology (CPT) codes and verified by International Classification of Disease, Ninth Revision (ICD-9) codes. Data on surgeon fellowship, practice location, concomitant surgical procedures, and complications were collected., Results: One hundred sixty-four UCL reconstructions were performed by 133 ABOS Part II candidates. The annual incidence increased from 1.52 to 3.46 cases per 10,000 (P = 0.042). Reconstructions were most commonly performed by surgeons with fellowship training in sports medicine (65.9%), hand and upper extremity (18.9%), and shoulder and elbow (9.1%). Most reconstructions were performed in isolation (57.3%), or with ulnar nerve transposition (32.9%) or elbow arthroscopy (9.8%). Concomitant elbow arthroscopy rates decreased significantly (P = 0.022). Complications occurred in 9.8% of cases, although the rates did not significantly change (P = 0.466)., Conclusions: UCL reconstructions are being performed with increasing frequency. Concomitant procedure rates remained the same, although arthroscopy was less commonly performed. Complication rates did not change considerably over the observed period. Further study of the surgical trends and associated long-term outcomes is warranted., Level of Evidence: Level IV.

Background: Though previous studies have shown improved outcomes associated with higher volume surgeons and hospitals, this may not be replicated in ASDS due to case complexity variation. We hypothesized that high-volume surgeons perform more complex surgeries. Therefore, we defined an Operative Complexity Index (OCI), specifically for the National Inpatient Samples (NIS) data, which provides information on in-hospital postoperative complications, to assess rates of adult spine deformity surgery (ASDS) cases as they relate to surgeon and hospital operative volume., Methods: The 2001 to 2010 NIS was queried for patients greater than 21 years of age with in-hospital stays, including a spine arthrodesis for a diagnosis of scoliosis. Surgeon and hospital identifiers were used to allocate records into volume quartiles by number of surgeries per year. The OCI was devised considering the number of fusion levels, surgical approach, revision status, and use of osteotomy. The index was validated using blood-loss-related diagnostic and procedural codes. One-way ANOVA assessed continuous measures. Chi-square assessed categorical measures., Results: 141,357 ASDS cases met the inclusion criteria. High-volume surgeons performed a higher rate of longfusions (> 8 levels), revision surgeries, and surgeries requiring osteotomy. The OCI showed weak, but significant, correlation with blood loss values: acute blood loss anemia (r = 0.21) and treatment with blood products (r = 0.12) (p < 0.001). High OCI also was also associated with increased length of stay (r = 0.27) and total charges (r = 0.41) (p < 0.001)., Conclusions: The operative complexity index (OCI) for ASDS increases with high-volume surgeons and centers, indicating it can be useful to adjust for surgical invasiveness in the NIS database. Operative complexity must be considered when evaluating patient safety and quality indices among hospitals and surgeons.

Purpose: A certified list of all operative cases performed within a six month period is required of surgeons by the American Board of Orthopaedic Surgery (ABOS) as a prerequisite to taking the Part II Oral Examination. Using the data on these cases collected and maintained by ABOS, this study assessed the influence of prior fellowship training in adult reconstruction on the volume and surgeon-reported complication rate of knee joint arthroplasty cases over time., Methods: All data were self reported to a secure Internet database (SCRIBE) by candidates who applied to take Part II of the ABOS Examination for the first time. This database was searched for all procedures done between 2003 and 2013 with CPT codes for total and revision knee arthroplasty and removal of knee implant (static or dynamic spacer) to determine procedural volumes and early complication rates among Board-eligible orthopaedic surgeons with and without adult reconstructive fellowship training., Results: More than 43,000 knee arthroplasty surgeries were identified. Surgeons who had completed adult reconstruction fellowship training after residency performed 55 % of total knee arthroplasties, averaging 33.5 knee arthroplasties during the six month case-collection period compared to 7.4 procedures by non-fellowship-trained surgeons (p < 0.001). Adult reconstruction fellowship-trained surgeons performed significantly more revisions for infection (average 6.6 versus 2.2 revisions) (p < 0.001). Adult reconstruction fellowship training did not significantly affect complication rates for primary arthroplasty but was associated with an increased complication rate for revisions. Those surgeons who performed more than 100 arthroplasties a year reported significantly fewer complications in primary arthroplasties (12.7 % versus 16.9 %) (p < 0.001). Over time, an increasing percentage of arthroplasties were done by surgeons with adult reconstruction fellowship training., Conclusions: Adult reconstruction fellowship-trained surgeons performed an increasing number of primary and more complex knee arthroplasties from 2003 to 2013. Surgeons who perform a larger volume of knee arthroplasty surgeries report fewer early complications than surgeons with fewer cases., Level of Evidence: 4.

Background: Although the number of women in surgical specialties has increased dramatically over the past two decades, little research exists regarding how a surgeon's gender impacts job selection and practice models. Because the number of women specializing in pediatric orthopaedics continues to increase, it is important to understand how one's gender affects practice choices and how this may affect the future workforce., Questions/purposes: (1) Among pediatric orthopaedic surgeons, is gender associated with choice of practice type (academic, private practice, hospital-based, solo)? (2) For men and women, what are the most common reasons for choosing a job? (3) For new graduates, do men and women have equal starting salaries? (4) Do men have a higher chance of getting job offers? (5) Is there a difference in workload (call frequency and surgical case volume) for men and women? (6) Finally, is there a difference in imminent retirement plans for men and women?, Methods: The 2015 Pediatric Orthopaedic Society of North American (POSNA) Needs Assessment Survey was sent to POSNA members and a special 36-question survey was sent to recent pediatric orthopaedic fellowship graduates. Both surveys included questions about self-reported gender, practice type, reasons for job selection, and call frequency. In addition, the new graduates' survey also included questions about starting salary, job offers, and number of additional fellowships completed. Responses were analyzed by gender. Chi-square and Fisher's exact tests assessed for statistical significance., Results: Among the new graduates, women are more likely to choose academic practice (women: 13 of 18 [72%], men: 21 of 44 [48%], odds ratio [OR], 3.10 [confidence interval {CI}, 0.86-11.10], p < 0.001), whereas men are more likely to choose private practice (men: 14 of 44 [32‰], women: one of 18 [6%], OR, 0.12 [CI, 0.015-1.001], p < 0.001). The primary reasons for choosing a job were not different between men and women. Among the new graduates, geography/family considerations were reported as being highly important when selecting a job (men: 33 of 44 [75%], women: 16 of 18 [89%]) followed by academic opportunities (men: 24 of 44 [55%], women: 14 of 18 [78%]). Interestingly, a higher percentage of males reported finances as being important when selecting a job (men: 23 of 44 [52%], women: five of 18 [28%]). For the current POSNA members, the most important reasons when choosing a job for both men and women were quality of partners (men: 168 of 408 [41%], women: 66 of 122 [54%]) and an interesting practice (men: 155 of 408 [38%], women 54 of 122 [44%]. As a result of our small sample size, there was no difference in starting salaries between men and women (< USD 350,000: men 22 of 44 [50%], women 12 of 18 [67%]; USD 350,000-450,000: men 11 of 44 [25%], women six of 18 [33%]; > USD 450,000: men eight of 44 [18%], women zero of 18 [0%], p = 0.131). When stratified by practice type, for private practice starting salaries, over half of men (seven of 13 [54%]) placed in the highest category of > USD 400,000, whereas the single woman respondent placed in the lowest category of < USD 300,000. Men were more likely to report having job offers before starting their fellowship (men: 24 of 44 [54%], women: eight of 18 [44%], OR, 0.67 [CI, 0.22-2.0], p = 0.042). Finally, among POSNA members, women reported a lower weekly surgical case volume compared with men. Of the men, 108 of 408 (26%) reported performing more than seven surgeries per week compared with 12 of 122 women (10%; OR, 3.4 [CI, 1.8-6.44], p < 0.001)., Conclusions: Although the numbers are small given the specialized nature of pediatric orthopaedic surgery, this study has uncovered some initial gender differences regarding practice characteristics and job opportunities among pediatric orthopaedic surgeons. As more men plan to reduce their workload or retire in the next 5 years, there may be further increases in the percentage of women surgeons in the workforce, so it is important that we begin to understand what effect, if any, gender has on practice patterns, job selection, and opportunities. Also, the finding that among the new graduates more women than men are choosing careers in academic practice over private practice suggests an extraordinary opportunity to develop more female leaders and role models at major pediatric orthopaedic centers.

Background: Women and minorities remain underrepresented in orthopaedic surgery. In an attempt to increase the diversity of those entering the physician workforce, Nth Dimensions implemented a targeted pipeline curriculum that includes the Orthopaedic Summer Internship Program. The program exposes medical students to the specialty of orthopaedic surgery and equips students to be competitive applicants to orthopaedic surgery residency programs. The effect of this program on women and underrepresented minority applicants to orthopaedic residencies is highlighted in this article., Questions/purposes: (1) For women we asked: is completing the Orthopaedic Summer Internship Program associated with higher odds of applying to orthopaedic surgery residency? (2) For underrepresented minorities, is completing the Orthopaedic Summer Internship Program associated with higher odds of applying to orthopaedic residency?, Methods: Between 2005 and 2012, 118 students completed the Nth Dimensions/American Academy of Orthopaedic Surgeons Orthopaedic Summer Internship Program. The summer internship consisted of an 8-week clinical and research program between the first and second years of medical school and included a series of musculoskeletal lectures, hands-on, practical workshops, presentation of a completed research project, ongoing mentoring, professional development, and counselling through each participant's subsequent years of medical school. In correlation with available national application data, residency application data were obtained for those Orthopaedic Summer Internship Program participants who applied to the match between 2011 through 2014. For these 4 cohort years, we evaluated whether this program was associated with increased odds of applying to orthopaedic surgery residency compared with national controls. For the same four cohorts, we evaluated whether underrepresented minority students who completed the program had increased odds of applying to an orthopaedic surgery residency compared with national controls., Results: Fifty Orthopaedic Summer Internship scholars applied for an orthopaedic residency position. For women, completion of the Orthopaedic Summer Internship was associated with increased odds of applying to orthopaedic surgery residency (after summer internship: nine of 17 [35%]; national controls: 800 of 78,316 [1%]; odds ratio [OR], 51.3; 95% confidence interval [CI], 21.1-122.0; p < 0.001). Similarly, for underrepresented minorities, Orthopaedic Summer Internship completion was also associated with increased odds of orthopaedic applications from 2011 to 2014 (after Orthopaedic Summer Internship: 15 of 48 [31%]; non-Orthopaedic Summer Internship applicants nationally: 782 of 25,676 [3%]; OR, 14.5 [7.3-27.5]; p < 0.001)., Conclusions: Completion of the Nth Dimensions Orthopaedic Summer Internship Program has a positive impact on increasing the odds of each student participant applying to an orthopaedic surgery residency program. This program may be a key factor in contributing to the pipeline of women and underrepresented minorities into orthopaedic surgery., Level of Evidence: Level III, therapeutic study.

Objectives: The purpose of this survey was to learn more about the indications, criteria, and methods surgeons use for performing examination under anesthesia (EUA) for "intermediate" sized posterior wall acetabular fractures (those involving 20% to 40% of the posterior wall) and to find what criteria are used to determine hip instability., Methods: An 18 question survey was posted on the Ortho- paedic Trauma Association's website and was used to gather anonymous data from orthopaedic surgeons regarding their approach to the intermediate sized posterior wall fracture., Results: Considerable variability existed among re- sponses to many of the questions asked. Based on the an - swers given to the survey, a consensus of 75% or more of respondents was found for the following: 1. Supine position for the examination (100%); 2. "Live" fluoroscopy is used during the examination (97%); 3. The AP and obturator oblique are the x-rays most frequently used (81% and 76%, respectively); 4. The hip is placed in flexion and adduction during the exam (100% and 84%, respectively); 5. Axial load is applied during the examination (90%); Finally, 6. instabil - ity is defined as subluxation on exam by most respondents (98%), and any perceived visible subluxation is what defines instability (88%)., Conclusion: Most surgeons agreed with the following: 1. Supine is the position of choice for the examination; 2. "Live" fluoroscopy is used during the examination; 3. The AP and obturator oblique are the x-rays most frequently used; 4. The hip is placed in flexion and adduction during the exam; 5. Axial load is applied during the examination; and 6. Instability is defined as subluxation on exam.

Background: Due to current and prospective demographic developments, the provision of high-quality medical care is not guaranteed in Germany., Objectives: The aim of this study is to analyze the utilization of medical service providers for diseases related to orthopedic/trauma surgery and deduce the corresponding number of medical service providers until 2050., Materials and Methods: Data provided by the Statistical Offices of the Federal Republic and the Federal States and the Scientific Institute of the AOK (2008-2012) were used to analyze the utilization behavior of four pre-determined orthopedic/trauma surgery disease groups (osteoarthritis, back pain, osteoporosis, trauma). Routine data of the current (2012) health care provision delivered by the compulsory health insurances (GKV) are the basis of the prognosis. Using population projections from the Federal Statistical Office, the health care demand until 2050 was predicted and using statistics from the German Medical Association, the number of required health care providers was determined., Results: An increase in physician consultations until 2040 is expected for osteoarthritis (+ 21 %), osteoporosis (26 %), and trauma (+ 13 %). From 2040-2050 the health care utilization behavior of all examined diseases is expected to decrease. The increasing health care usage behavior until 2040 is associated with an increase in health care providers., Conclusions: Until 2030 a significant increase in the burden of orthopedic/trauma surgery diseases is expected. In 2050 the level of health care needs will be equivalent to that in 2030. Comprehensive needs assessment and planning are needed in order to create health care provision structures and processes that address potential changes in utilization behavior.