For Surgically Treated Geriatric Acetabular Fractures, Longer Duration between Admission and Surgery Is Associated with an Increase in Post-operative Complications: A Study Using the National Trauma Data Bank.

INTRODUCTION: The purpose of this study was to determine whether time from hospital admission to surgery is associated with inpatient complications and mortality for geriatric patients undergoing surgical treatment of acetabular fractures. METHODS: This was a retrospective cohort study using the National Trauma Data Bank from 2016 to 2018 of patients presenting to level I through IV trauma centers in the United States. All patients aged 60 years or older with acetabular fractures requiring surgical treatment were included. The main outcome measurements were inpatient mortality and complication rates. RESULTS: There were 6,036 patients who met inclusion criteria. The median age was 69 years (interquartile range 64-76 years). The odds of a complication increased by 7% for each additional day between hospital admission and surgery (multivariable regression OR 1.07, 95% CI = 1.04 to 1.10; P < 0.001). Complications were also associated with patient age (OR 1.05, 95% CI = 1.03 to 1.06; P < 0.001) and mCCI ≥ 5 (OR 2.52, 95% CI = 1.4 to 4.2; P = 0.001). Inpatient mortality was not associated with time to surgery (OR 0.97, 95% CI = 0.92 to 1.02; P = 0.30), but was associated with patient age (OR 1.07, 95% CI = 1.05 to 1.10; P < 0.001; P < 0.001) and mCCI ≥ 5 (OR 4.62, 95% CI = 2.31 to 8.50; P < 0.001). DISCUSSION: In this database study, time from hospital admission to surgery was associated with a notable increase in inpatient complications but not inpatient mortality after adjusting for potentially confounding variables while age and mCCI were associated with both mortality and complications. Additional research is needed to determine the relationship between time to surgery with longer term mortality and complications and to assess causality. LEVEL OF EVIDENCE: Prognostic Level III.

Fractures of the posterior malleolus: a systematic review and analysis of patient-reported outcome scale selection.

PURPOSE: Despite the extensive use of PROs in ankle fracture research, no study has quantified which PROs are most commonly used for assessing outcomes of patients who sustain fractures of the posterior malleolus. The purpose of this study was therefore to quantify which PROs are most commonly used for outcome research after posterior malleolus fractures. METHODS: A systematic search was performed using the preferred reporting items for systematic reviews and meta-analyses guidelines. Articles were identified through Pubmed, EMBASE, Web of Science, and cochrane central register of controlled trials through May of 2021. Included articles were analyzed for the primary outcome of the most commonly reported PRO. RESULTS: The American orthopedic foot and ankle ankle-hindfoot score (AOFAS) was the most commonly used PRO for assessment of posterior malleolus fracture outcomes, used in 37 of 72 studies (51.4%). The second and third most common were the olerud-molander ankle score (OMAS) (22 studies, 30.6%) and the visual analogue score (VAS) (21 studies, 29.2%). Eleven different PROs were used only once. Quality of evidence was graded as low given the percentage of studies that were observational or case series (68 of 72 studies, 94.4%). CONCLUSION: Investigators have used many different PROs to assess outcomes for posterior malleolus fractures, the most common of which are the AOFAS, OMAS, and VAS. Future investigators should attempt to unify outcome reporting for these injuries.

Revision Surgery and Wound Complications with Minimally Invasive Compared to Open Achilles Tendon Repair: A Retrospective Comparative Study of 116 Patients.

The current study analyzed revision surgery rate and wound complications of patients with Achilles tendon ruptures that received either minimally invasive repair or open standard repair. A retrospective chart review of patients that had Achilles tendon repair performed using either an open or minimally invasive technique was conducted. Primary outcomes were revision surgery rate and wound complication rate. Twenty-nine (25.0%) patients had the minimally invasive approach, while 87 (75.0%) had the open approach. On average there were 0.16 additional surgeries per patient in the open group versus none in the minimally invasive group (p = 0.003). There were 13 wound-related complications, all of which were in the open group (p = 0.06). Revision surgery rates are significantly higher for patients treated with open Achilles repair versus those treated with a minimally invasive technique. Patients may benefit from a minimally invasive as opposed to open technique. (Journal of Surgical Orthopaedic Advances 32(3):173-176, 2023).

Mortality Rate Increase in Elderly Patients With Hip Fractures Presenting During the COVID-19 Pandemic to a Hospital in the United States Epicenter: Minimum 30-day Follow Up Comparative Study.

The purpose of this study was to compare mortality and complication rates among geriatric patients who sustained a hip fracture before the coronavirus disease (COVID-19) pandemic began to those who presented during the peak of the pandemic. Patients greater than or equal to 50 years of age who presented with a diagnosis of hip fracture from March 16, 2020 to May 1, 2020 were compared with a historical control group who presented between December 1, 2019 and January 16, 2020. Minimum follow up was 30 days. The primary outcome was a 30-day mortality rate. Thirty-day mortality was significantly different between groups, with no deaths of 24 patients in the pre-COVID-19 cohort versus six deaths of 23 patients (26.1%) in the COVID-19 cohort (chi-squared test, p-value = 0.02). The study concluded that the COVID-19 pandemic increased mortality risk for geriatric hip fracture patients. (Journal of Surgical Orthopaedic Advances 32(4):232-237, 2023).

Anatomic Risks with Overpenetration of the Volar Locking Plates' Proximal Holes.

Background Volar locking plate fixation (VLP) is commonly used to treat distal radius fractures (DRF). Risk of dorsal compartment injury with distal screw hole fixation has been studied; however, the risk with proximal screw hole fixation is not well studied. Purpose The goal of this study was to investigate the risk of dorsal structure injury from the screw holes proximal to the two distal rows. Methods Nine cadaveric forearms were used. After volar distal radius exposure, a long VLP was applied. Kirschner wires were placed through the most proximal holes into the dorsal compartments. The extensor structures penetrated were noted and tagged with hemoclips. The distance from the dorsal cortex to the structures was measured. Results The abductor pollicis longus (APL) and extensor pollicis brevis (EPB) muscle bodies were only penetrated; no tendons were penetrated. Proportion of muscle penetration increased with the more proximal screw holes. EPB was more likely to be penetrated distally and APL proximally; both were injured at holes 2 and 3. The extensors were 2 mm from the dorsal cortex of the radius on average; this did not decrease with compression of the forearm. Conclusions This is the first study to examine the anatomic risk of extensor structure injury with VLP proximal screw hole penetration. No extensor tendons were penetrated by these proximal screw holes; first dorsal compartment muscle bellies may be irritated with overpenetration. Our findings suggest that proximal VLP screws do not need to be downsized if they are not over 2 mm prominent.

Venous thromboembolism prophylaxis with low molecular weight heparin versus unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures.

Background: The objective of this study was to compare inpatient mortality rates for patients with operatively treated closed femoral shaft fractures (AO/OTA 32 A-C) who received venous thromboembolism (VTE) prophylaxis with either low molecular weight heparin (LMWH) or unfractionated heparin. Methods: This was a retrospective cohort study of a national database of patients presenting to Level I through IV trauma centers in the United States. All patients ≥18 years of age who sustained an operatively treated closed femoral shaft fracture were included. The primary outcome of inpatient mortality was compared between two groups: those who received LMWH or unfractionated heparin for VTE prophylaxis. Secondary outcomes were complications including VTE and bleeding events. Groups were compared using a multivariate regression model. Results: There were 2058 patients included in the study. Patients who received VTE prophylaxis with LMWH had lower odds of inpatient mortality compared to patients who received VTE prophylaxis with unfractionated heparin (OR 0.19; 95% CI 0.05 to 0.68, p = 0.011). Conclusions: VTE prophylaxis with LMWH is associated with lower inpatient mortality compared to VTE prophylaxis with unfractionated heparin for patients undergoing operative treatment of closed femoral shaft fractures. To our knowledge this is the first study to report these associations for a specific subset of orthopedic trauma patients.

Instagram Use Among Orthopaedic Surgery Residency Programs.

INTRODUCTION: The COVID-19 pandemic created unprecedented challenges to residency recruitment. With in-person away rotations prohibited and interviews held virtually, orthopaedic residency programs turned to social media. Studies document the exponential growth of residency program Instagram accounts after March 2020, but few analyze the content of their posts. This study provides an updated assessment of such Instagram accounts including a detailed analysis of their content and a discussion of potentially concerning posts. METHODS: Orthopaedic surgery residency programs participating in the National Resident Matching Program and any Instagram accounts associated with these programs were identified. Instagram accounts were analyzed, and the 25 most recent posts and all highlighted stories for each account were coded for content based on a predetermined list of categories. Specific attention was given to content that may raise legal, ethical, or professionalism concerns. The primary outcome was the most common content code among posts. The secondary outcomes were the number of posts identified as potentially concerning and the types of concerns represented. RESULTS: Overall, 138 of 193 residency programs (72%) had an Instagram account at the time of cross-sectional analysis, 65% of which were created between April and December 2020. All accounts were public. Profiles had on average 1,156 ± 750 followers and 59 ± 75 posts. Of the 3,348 posts analyzed, the most common coded themes were resident introductions (33%), camaraderie (27%), and social life and hobbies (26%). There were 81 concerning posts from 52 separate accounts. Seventy-five of the concerning posts (93%) depicted residents scrubbed alone. CONCLUSION: Orthopaedic residency Instagram accounts are potential tools for residency recruitment and can depict a program's culture through posts over time. However, public accounts are open to scrutiny by other viewers, including patients and their families. Care must be taken to consider multiple perspectives of post content, so as to bolster, not damage, the residency program's reputation.

Artificial Learning and Machine Learning Applications in Spine Surgery: A Systematic Review.

OBJECTIVES: This current systematic review sought to identify and evaluate all current research-based spine surgery applications of AI/ML in optimizing preoperative patient selection, as well as predicting and managing postoperative outcomes and complications. METHODS: A comprehensive search of publications was conducted through the EMBASE, Medline, and PubMed databases using relevant keywords to maximize the sensitivity of the search. No limits were placed on level of evidence or timing of the study. Findings were reported according to the PRISMA guidelines. RESULTS: After application of inclusion and exclusion criteria, 41 studies were included in this review. Bayesian networks had the highest average AUC (.80), and neural networks had the best accuracy (83.0%), sensitivity (81.5%), and specificity (71.8%). Preoperative planning/cost prediction models (.89,82.2%) and discharge/length of stay models (.80,78.0%) each reported significantly higher average AUC and accuracy compared to readmissions/reoperation prediction models (.67,70.2%) (P < .001, P = .005, respectively). Model performance also significantly varied across postoperative management applications for average AUC and accuracy values (P < .001, P < .027, respectively). CONCLUSIONS: Generally, authors of the reviewed studies concluded that AI/ML offers a potentially beneficial tool for providers to optimize patient care and improve cost-efficiency. More specifically, AI/ML models performed best, on average, when optimizing preoperative patient selection and planning and predicting costs, hospital discharge, and length of stay. However, models were not as accurate in predicting postoperative complications, adverse events, and readmissions and reoperations. An understanding of AI/ML-based applications is becoming increasingly important, particularly in spine surgery, as the volume of reported literature, technology accessibility, and clinical applications continue to rapidly expand.

Clinical Trial Quality Assessment in Adult Spinal Surgery: What Do Publication Status, Funding Source, and Result Reporting Tell Us?

STUDY DESIGN: Narrative Review. OBJECTIVES: The objective of this study was to compare publication status of clinical trials in adult spine surgery registered on ClinicalTrials.gov by funding source as well as to identify other trends in clinical trials in adult spine surgery. METHODS: All prospective, comparative, therapeutic (intervention-based) trials of adult spinal disease that were registered on ClinicalTrials.gov with a start date of January 1, 2000 and completion date before December 17, 2018 were included. Primary outcome was publication status of published or unpublished. A bivariate analysis was used to compare publication status to funding source of industry vs non-industry. RESULTS: Our search identified 107 clinical trials. The most common source of funding was industry (62 trials, 57.9% of total), followed by University funding (26 trials, 24.3%). The results of 76 trials (71.0%) were published, with industry-funded trials less likely to be published compared to non-industry-funded trials (62.9% compared to 82.2%, P = .03). Of the 31 unpublished studies, 13 did not report any results on ClinicalTrials.gov, and of those with reported results, none was a positive trial. CONCLUSIONS: Clinician researchers in adult spine surgery should be aware that industry-funded trials are less likely to go on to publication compared to non-industry-funded trials, and that negative trials are frequently not published. Future opportunities include improvement in result reporting and in publishing negative studies.

Recent Trends in Private Equity Acquisition of Orthopaedic Practices in the United States.

BACKGROUND: Private equity acquisition of medical specialty practices has increased in recent years. With the projected increase in the volume of elective, ambulatory orthopaedic procedures, especially in the outpatient setting, private equity firms are increasingly investing in orthopaedic practices. The purpose of this cross-sectional study was to report recent trends and variations in acquisitions of US orthopaedic practices by private equity firms and other institutional investors (venture capital firms, trusts, and large investment companies). METHODS: Acquisition data through January 1, 2020, were collected and analyzed using various financial databases, supplemented with publicly available information from financial news outlets, press releases, and financial analyst and industry reports. Disclosed financing data were also included, in addition to pertinent geographic information (state, city, and zip code) of the target practices. RESULTS: Between 2004 and 2019, 41 orthopaedic practices and surgeon groups across 22 states were acquired by 34 private equity and other investment firms. A significant increase was observed in the number of acquisitions between 2017 and 2019, consisting of 70.7% of total transactions during the study period, with a statistically significant upward yearly trend (P = 0.002). The compound annual growth rate in acquisition volume was 29.2% during the study period. A disproportionate share of private equity acquisitions took place in the South, where more than half (51.2%) of the total transactions took place. Firms were markedly more likely to acquire or invest in practices located in major metropolitan areas (population more than 1 million) compared with those in mid-sized or rural areas (70.7%, 17.1%, 12.2%, respectively; P < 0.001). CONCLUSIONS: Private equity acquisition of orthopaedic surgery practices has increased markedly in recent years. The effect of private equity acquisition on physician independence, practice management, and procedure reimbursement remains unclear and may be important to explore as practice management evolves. LEVEL OF EVIDENCE: Prognostic Level III.

Current Status of Podcasts in Orthopaedic Surgery Practice and Education.

Within orthopaedic surgery, podcasts are a popular medium for sharing information. The purpose of this Training Room feature was to identify the number, type, longevity, popularity, and advantages and disadvantages of orthopaedic surgery podcasts and to better understand the role of podcasts in our field by interviewing key leaders in orthopaedic surgery who host their own podcast. We identified 102 unique orthopaedic podcasts. The number of active podcasts grew from 5 in 2016 to 67 in 2021, which represents an increase of 1,340%. Podcasts offer the advantages of easy access to knowledge and opportunity for multitasking. They come with the disadvantages of lack of visualization in a field that relies heavily on diagrams, photographs, videos, and radiographs and lack of peer review, which means false information may be propagated. We anticipate an increase in the number and popularity of orthopaedic surgery podcasts in the coming years.

Economic Impact of Unused Surgical Instruments in an Orthopaedic Surgery Department at an Academic Medical Center: A Prospective Cross-sectional Study.

Orthopaedic surgical trays contain unused instruments, but we do not know which specific instruments go unused nor do we know the savings from eliminating them from a given tray. This was a single-site, observational study conducted at an academic medical center. The primary outcome was type of unused instruments and percentage of instruments used in two commonly used surgical trays. The secondary outcome was cost savings in United States dollars (USD) that could be attained by eliminating these instruments. In the first tray, five instruments (10.6%) were unused in any of 37 observed cases. In the second tray, nineteen instruments (19.6%) were unused in 37 observed cases. The total annual savings from replacement cost analysis and reprocessing cost analysis was $6,597.00 USD. Unused instruments are common in surgical trays. Eliminating unused instruments can result in immediate cost savings. (Journal of Surgical Orthopaedic Advances 30(3):131-135, 2021).

Neck and Back Sprain and Hand Flexor Tendon Repair Are More Common in Victims of Domestic Violence Compared With Patients Who Were Not Victims of Domestic Violence: A Comparative Study of 1,204,596 Patients Using the National Trauma Data Bank.

INTRODUCTION: The purpose of this study was to determine the most common orthopedic diagnoses and procedures among patients who experience domestic violence (DV) and to determine whether these were more common in patients who experienced DV compared with those who did not. METHODS: We performed a retrospective cohort study of all patients identified in the National Trauma Data Bank. Patients were divided into two cohorts for comparison: victims of DV and all other patients. The main outcome measurements were a diagnosis of an orthopedic injury and/or a procedure performed for an orthopedic diagnosis. RESULTS: In total, 1,204,596 patients were included in the analysis, of whom 3191 (0.26%) were victims of DV. Adult trauma patients with DV were more likely to have a diagnosis of neck and back sprain (odds ratio 1.98, 95% confidence interval 1.60 to 2.44, P < 0.0001) and more likely to undergo surgical repair of the flexor tendon of the hand (odds ratio 2.76, 95% confidence interval 1.75 to 4.35, P < 0.0001) than patients without a diagnosis of DV. DISCUSSION: Patients who experience DV were more likely to have back and neck sprain and more likely to undergo repair of flexor tendon of the hand than those who do not experience DV.

The Fragility of Statistical Findings in Achilles Tendon Injury Research: A Systematic Review.

INTRODUCTION: Probability analysis with the reporting of P values is often used to determine the statistical significance of study findings in the Achilles literature. The purpose of this study was to determine the utility of applying a fragility analysis to comparative trials evaluating Achilles tendon injuries. METHODS: We identified all dichotomous outcome data for comparative studies of Achilles tendon injuries published in 11 orthopaedic journals from 2000 to 2020. The fragility index (FI) was determined by the number of event reversals required to change a P value from less than 0.05 to greater than 0.05, or vice-versa. The associated fragility quotient was determined by dividing the FI by the sample size. RESULTS: Of the 51,357 studies screened, 1,487 met the search criteria, with 51 comparative studies and 177 total outcome events included for analysis. The overall FI was only 4 with an associated fragility quotient of 0.048. One-half of the studies failed to report lost to follow-up data, with an additional 21.6% reporting loss to follow-up of greater than or equal to 4. CONCLUSION: Our fragility analysis suggests that Achilles tendon injury outcomes are not as statistically stable as previously thought and should be interpreted with caution.

Patient-Reported Outcome Measurement Information System (PROMIS) in Orthopaedic Trauma Research.

This review describes the development, advantages and disadvantages, and applications of the Patient-Reported Outcome Measurement Information System (PROMIS) in orthopaedic trauma. PROMIS is a useful tool for quantifying outcomes in orthopedic trauma. It allows measurement of outcomes across multiple domains while minimizing administration time. PROMIS also reliably identifies clinical, social, and psychological risk factors for poor outcomes across a variety of orthopaedic injuries and disease states. However, PROMIS lacks specificity for certain anatomic regions and validation for mental health outcomes. It also is limited by ceiling effects in certain active patient populations. Orthopaedic traumatologists should be familiar with PROMIS, as its use is increasing and it is a valuable tool that can aid in clinical decision making.

Debate Update: Surgery After 48 Hours of Admission for Geriatric Hip Fracture Patients Is Associated With Increase in Mortality and Complication Rate: A Study of 27,058 Patients Using the National Trauma Data Bank.

OBJECTIVE: To determine the association between surgical timing and short-term morbidity and mortality in elderly patients who sustain hip fractures using a national trauma database (OTA/AO 31A1-3, 31B1-3). DESIGN: Retrospective cohort study. SETTING: Level I-IV trauma centers in the United States. PATIENTS/PARTICIPANTS: All patients ≥65 years of age who underwent surgery for hip fracture from 2011 to 2013. INTERVENTION: Time to surgery of <24, 24-48, and >48 hours from admission. MAIN OUTCOME MEASUREMENTS: Primary outcome was mortality by hospital discharge. Secondary outcomes were complications of myocardial infarction, cardiac arrest, acute respiratory distress syndrome (ARDS), unplanned reintubation, pneumonia, stroke, severe sepsis, and intensive care unit length of stay. RESULTS: Twenty-seven thousand fifty-eight patients were included in the study. Relative to the <24 hours cohort, patients in the >48 hours cohort were at increased risk for mortality (OR 1.89, 95% CI 1.52-2.33, P < 0.001), ARDS (OR 2.57, 95% CI 1.94-3.39, P < 0.001 for ARDS), myocardial infarction (OR 2.19, 95% CI 1.64-2.94, P < 0.0001), pneumonia (OR 2.04, 95% CI 1.71-2.44, P < 0.001), severe sepsis (OR 2.34, 95% CI 1.52-3.58, P = 0.003), and intensive care unit stay (OR 2.48, 95% CI 2.25-2.74, P < 0.0001). A subgroup analysis showed that healthier patients (modified Charlson Comorbidity Index less than 5) who had surgery >48 hours were not at increased risk of mortality. CONCLUSIONS: For elderly patients with hip fractures, delaying surgery for more than 48 hours may be associated with increased short-term morbidity and mortality. This association may be pronounced for patients with more medical comorbidities. LEVEL OF EVIDENCE: Therapeutic Level III. See Instructions for Authors for a complete description of levels of evidence.

Number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation is associated with complication rate.

INTRODUCTION: Surgical treatment of distal humerus fractures can lead to numerous complications. Data suggest that the number of screws in the distal (articular) segment may be associated with complication rate. The purpose of this study is to evaluate the association between a number of screws in the distal segment and complication rate for surgical treatment of distal humerus fractures. We hypothesize that the number of screws in the articular segment of distal humerus AO/OTA C-type fractures treated with open reduction internal fixation (ORIF) will be inversely proportional to the complication rate. METHODS: We performed a single-center retrospective cohort study of 27 patients who underwent ORIF of distal humerus fractures C-type with at least six months of radiographic and clinical follow-up. Clinical outcomes including a range of motion, pain, revision surgery for stiffness and/or heterotopic ossification (HO), nonunion, and persistent ulnar nerve symptoms requiring revision neurolysis were recorded. RESULTS: In C-type fractures, the use of three or fewer articular screws was significantly associated with nonunion or loss of fixation (RR 17, p = 0.006). Nineteen of 36 (53%) patients experienced at least one complication. The surgical approach, plate configuration, age, and ulnar nerve treatment (none, in situ release, transposition) were not associated with the need for revision surgery. Men had a higher risk of requiring surgical contracture release due to improving post-operative stiffness (RR 12, p = 0.02). CONCLUSION: In this retrospective study, the use of three or fewer screws to fix articular fragments in AO type C fractures was a significant risk for nonunion or loss of fixation. Plate configuration and surgical approach did not correlate with outcomes. Men had higher rates of complications and required more frequent revision surgery compared to women.

Risk Factors for Surgical Site Infection in Orthopaedic Oncology.

INTRODUCTION: Surgical site infections (SSIs) are common complications after surgeries involving musculoskeletal tumors, but we know little about SSI risk factors unique to orthopaedic oncology. A greater understanding of these factors will help risk-stratify patients and guide surgical decision-making. METHODS: A retrospective review at a single-institution identified 757 procedures done on 624 over 6 years. The patients had a preoperative diagnosis of a malignant or potentially malignant neoplasm of the bone or soft tissues. Patient-specific and procedure-specific variables and diagnosis of SSI were recorded for each case. Data were analyzed through univariate analysis and multiple logistic regression. RESULTS: On univariate analysis, significant patient-specific risk factors for SSI included malignancy (P < 0.001), smoking history (P = 0.041), and American Society of Anesthesiologists Score (P = 0.002). Significant procedure-specific risk factors for SSI on univariate analysis included surgery time (P < 0.001), estimated blood loss (P < 0.001), blood transfusion volume (P < 0.001), neoadjuvant chemotherapy (P < 0.001), neoadjuvant radiation therapy (P < 0.001), inpatient surgery (P < 0.001), and number of previous surgeries within the study period (P < 0.001). The two factors that independently predicted risk of SSI when controlling for all other variables in a multiple logistic regression were whether the surgery was done on an inpatient basis (P = 0.005) and the number of previous surgeries done on the same site (P = 0.001). CONCLUSIONS: We found a number of risk factors that correlate markedly with SSI after orthopaedic oncology surgery. The surgeon can use these risk factors to aid in surgical decision-making.

The Impact of the COVID-19 Pandemic on Orthopaedic Surgery Residency Applicants During the 2021 Residency Match Cycle in the United States.

INTRODUCTION: The purpose of this study was to quantify the impact of the COVID-19 pandemic on rising fourth-year medical students' plans to apply to residency in orthopaedic surgery. METHODS: We conducted a survey of rising fourth-year medical students. Primary outcome was the change in students' plans to apply to residency in orthopaedic surgery as measured by Likert scale response. Secondary outcomes were students' concerns about applying to residency during the pandemic. RESULTS: A total of 462 students were planning to apply to residency in orthopaedic surgery. Women said that they were "less likely" to apply to orthopaedic surgery because of the pandemic (14.9% versus 5.5% of men, P < 0.001). Students identifying as Black/African American said that they were "less likely" to apply (16.9% compared with 8.8 of non-Hispanic White, P < 0.001). Students said that they had "somewhat fewer" or "many fewer" opportunities to get adequate exposure to orthopaedic surgery to make a specialty choice (88.9% of students). DISCUSSION: We support the development of robust student advising and mentorship networks to address the uncertainty inherent in applying to residency during a global pandemic and curtail the racial and sex disparities discovered in this survey.