Minimal Clinically Important Difference (MCID) for the Short Musculoskeletal Function Assessment (SMFA) in Severe Lower Extremity Trauma: Pooled Data from 7 Multicenter, Prospective Clinical Trials.

BACKGROUND: The Short Musculoskeletal Function Assessment (SMFA) is a well validated, widely used patient-reported outcome (PRO) measure for orthopaedic patients. Despite its widespread use and acceptance, this measure does not have an agreed upon minimal clinically important difference (MCID). The purpose of the present study was to create distributional MCIDs with use of a large cohort of research participants with severe lower extremity fractures. METHODS: Three distributional approaches were used to calculate MCIDs for the Dysfunction and Bother Indices of the SMFA as well as all its domains: (1) half of the standard deviation (one-half SD), (2) twice the standard error of measurement (2SEM), and (3) minimal detectable change (MDC). In addition to evaluating by patient characteristics and the timing of assessment, we reviewed these calculations across several injury groups likely to affect functional outcomes. RESULTS: A total of 4,298 SMFA assessments were collected from 3,185 patients who had undergone surgical treatment of traumatic injuries of the lower extremity at 60 Level-I trauma centers across 7 multicenter, prospective clinical studies. Depending on the statistical approach used, the MCID associated with the overall sample ranged from 7.7 to 10.7 for the SMFA Dysfunction Index and from 11.0 to 16.8 for the SMFA Bother Index. For the Dysfunction Index, the variability across the scores was small (<5%) within the sex and age subgroups but was modest (12% to 18%) across subgroups related to assessment timing. CONCLUSIONS: A defensible MCID can be found between 7 and 11 points for the Dysfunction Index and between 11 and 17 points for the Bother Index. The precise choice of MCID may depend on the preferred statistical approach and the population under study. While differences exist between MCID values based on the calculation method, values were consistent across the categories of the various subgroups presented. LEVEL OF EVIDENCE: Prognostic Level III. See Instructions for Authors for a complete description of levels of evidence.

Pickleball-Related Fractures in the United States From 2002 to 2022: An Analysis Using the NEISS Database.

Background: Pickleball is one of the fastest-growing sports in the United States, with more than an 11-fold increase in injuries from 2010 to 2019. Purpose: To (1) determine the prevalence and demographic variables associated with pickleball-related fractures among patients evaluated at emergency departments in the United States between 2002 and 2022 and (2) identify variables influencing patient disposition status. Study Design: Descriptive epidemiology study. Methods: The US Consumer Product Safety and Commission's publicly available database, the National Electronic Injury Surveillance System (NEISS), was used in this study. Analyses consisted of descriptive statistics for fracture prevalence and demographic variables as well as univariate analysis for disposition status (discharged home vs hospital admission). Results: A total of 397 pickleball-related fractures were recorded between 2002 and 2022, which indicated a 90-fold increase in our study period. Based on weighted national average of NEISS sampling, this equated to approximately 5400 fractures annually. Players who sustained pickleball fractures were primarily aged >60 years (n = 344 [87%]; P < .001) and female (n = 273 [69%]; P < .001). Most fractures involved the upper extremity (n = 262 [66%]; P < .001), with the most common ones involving the radius (n = 79 [30%]), humerus (n = 22 [8%]), and ulna (n = 8 [3%]). Fractures were due most commonly to falls (n = 365 [92%]; P < .001) and occurred in the winter months (n = 142 [36%]; P < .001). There was a significant difference in disposition status, with most patients discharged (n = 320 [81%] vs n = 77 [19%] for hospital admission; P < .001). Univariate analysis revealed that age >60 years, male sex, and fractures to the trunk and lower extremity all led to significantly increased odds of being admitted (odds ratios: 2.27, 2.31, 2.89, and 13.8, respectively). Conclusion: Between 2002 and 2022, there was a 90-fold increase in pickleball-related fractures. Most fractures were of the upper extremity after a fall in women aged >60 years. Despite female fracture predominance, men were 2.3 times more likely to be admitted after sustaining a fracture.

Survey results of COVID-19 pandemic on female surgical trainees: New normal work environment.

BACKGROUND: The COVID-19 pandemic has had a profound impact on surgical training globally. We aimed to explore and identify the specific challenges faced by women surgeons during the pandemic and provide recommendations for improvement. METHODS: A survey was conducted among trainee members of the Association of Women Surgeons, assessing various aspects of clinical training, mental well-being, and personal and professional life. RESULTS: The respondents were distributed across the United States, with the majority (28%) from the Midwest and Northeast. Training settings were predominantly academic university hospital programs (85%). The majority (92%) were resident trainees and 32% were in research. General surgery, constituting 86% of the respondents, was the most common specialty. There was a decline in surgical cases, research, mental health, and quality of didactics. Limited learning opportunities and challenges in job search were reported. Although virtual conferences were deemed affordable, the lack of networking was noted to be significant. CONCLUSION: The study highlights the need for ongoing support and adaptation in surgical training programs. These programs include the optimization of virtual platforms, prioritizing mental well-being, and ensuring equal opportunities. Strategies to mitigate the impact of future disruptions and promote gender equality are essential. Further research and workflow changes are warranted for effective capacity building.

Major Metropolitan Area COVID-19 - Positive Patients Undergoing Emergency and Elective Orthopaedic Surgeries: A Case-matched Control Study.

The SARS-CoV-2 pandemic affected surgical management in Orthopaedics. This study explores the effect of COVID-19-positive patients on time to surgery from admission, total time spent in preoperative preparation, costs of orthopaedic care, and inpatient days in COVID-19-positive patients. The authors' case-matched study was based on the surgeon, procedure type, and patient demographics. The authors reviewed 58 cases, 23 males and 35 females. The results for the COVID-19-positive and -negative groups are time to admission (362.9; 388.4), time in preparation (127.8; 122.3), inpatient days to surgery (0.2; 0.2), and orthopaedic cost ($81,938; $86,352). With available numbers, no significant difference could be detected for inpatient days until surgery, any associated time to surgery, or orthopaedic costs for operating on COVID-19-positive patients during the pandemic. Perceived increased time and cost of care of COVID-19-positive patients were not proven in this study. (Journal of Surgical Orthopaedic Advances 33(1):014-016, 2024).

Women in Orthopaedics: 10-Year Trends of Fellowship Match Rate and Subspecialty.

BACKGROUND: Orthopaedic surgery has consistently remained one of the least diverse specialties in medicine. There are limited data on the match rate by sex into orthopaedic fellowships. PURPOSE: The goals of this study were to determine (1) how the percentage of women applying to orthopaedic fellowships has changed from 2011 to 2021, (2) whether there was a correlation between sex and the likelihood of a successful fellowship match, and (3) which subspecialties tend to have a greater proportion of female applicants and fellows. METHODS: The San Francisco (SF) Match service was used to obtain US orthopaedic fellowship applicant data from 2010 to 2021. San Francisco Match has run the match for the orthopaedic fellowship match since 2010. International medical graduates' applications, incomplete applications, or withdrawn applications were excluded. The following variables were collected and assessed: sex, subspecialty choice (except for hand because they do not use SF Match services), and match outcome. The number of female applicants and matches was recorded by year and compared with the number of male applicants and matches. Chi-square analysis was used to analyze categorical variables. RESULTS: A total of 6969 applicants to all orthopaedic specialties within SF Match were included during the study period. Overall, 859 were female (12.3%), and 6110 were male (87.7%). The number of female applicants had an increasing trend over the 10-year period from 65 applicants in 2011 to 111 in 2021. The overall proportion of female applicants was between 10.1% and 14.4%. The annual match rate for female applicants was 90.7% to 100% during the study period while the match rate for male applicants was 93.7% to 97.3%. Regarding successful matches, pediatrics had the highest proportion of women (range: 30.2% to 46.2%), followed by foot and ankle (range: 9.8% to 26.4%). Spine (range: 3.2 to 10.9%) and adult reconstruction (range: 3.9% to 9%) had the least number of women among matched applicants. DISCUSSION: This study found that the number of female applicants to orthopaedic fellowships has increased over the past 10 years. The difference in fellowship match rates among male versus female applicants did not statistically differ during this 10-year period; however, the proportion of female fellows is not equally distributed among subspecialties, with a higher proportion of women matching into pediatrics and foot and ankle and lower proportion in reconstruction and spine. These data can provide a benchmark for department chairs and society leadership to ensure they are recruiting, interviewing, and selecting candidates who are representative of the current sex demographics of orthopaedic fellowship graduates.

Evaluation of obesity and age as a predictive factor of lower extremity compartment syndrome: A national trauma data bank analysis.

BACKGROUND: Risk factors of acute compartment syndrome (ACS) of the leg include tibial fractures followed by soft tissue injuries. METHODS: Data collected from the National Trauma Data Bank (NTDB) between 2017 and 2019 were analyzed for adult patients with lower extremity fractures, including proximal tibia, tibial shaft, and distal tibia. The primary outcome was a diagnosis of ACS. RESULTS: There were 1052/220,868 patients with lower extremity fractures with a concomitant diagnosis of compartment syndrome. Our study has shown that patients with a BMI of ≥30 had a lower incidence of compartment syndrome when compared with patients with a BMI of 25-29 and controlled for fracture type. Increased age ≥55 in males, and females between 65 and 84, also demonstrated a decreased risk. Proximal tibial fractures (n â€‹= â€‹54,696) were significantly associated with ACS compared to midshaft (n â€‹= â€‹42,153) and distal (n â€‹= â€‹100,432), p â€‹< â€‹0.0001. CONCLUSION: We found that being overweight decreases risk for development of compartment syndrome in patients with lower extremity fractures. This big data study aids in establishing risk factors for development of ACS in adult trauma patients.

The Sex or Race of Program Directors May Not Play a Significant Role in Impacting Diversity Among Orthopaedic Surgery Residents.

PURPOSE: To identify the influence of residency program characteristics, including the presence of under-represented minorities in medicine (URiM) and/or female program directors (PDs), on the race and sex distribution of orthopaedic surgery residency trainees. METHODS: All active and Accreditation Council for Graduate Medical Education-accredited orthopaedic surgery residency programs from 2017-2021 that reported usable information in the Residency Explorer Tool were included. Data collected included program characteristics, as well as faculty and resident sex distribution, ethnicity, race, and demographic characteristics. The PDs' specific sex, ethnicity, race, and demographic characteristics were collected using residency program websites. The prevalence of factors in programs with the top quartile of female and URiM residents was compared with that in programs with the bottom 3 quartiles. RESULTS: Data were obtained from 148 of 200 Accreditation Council for Graduate Medical Education-accredited programs (3,694 residents). The 52 excluded programs had no usable information in the Residency Explorer Tool or on an identifiable program website. Overall, 15.9% of residents in orthopaedic surgery residency programs were women and 14% were under-represented minorities. The rates of female PDs and chairs were 12.4% and 6.9%, respectively, whereas those of URiM PDs and chairs were 8.3% and 4.6%, respectively. Programs with more female residents were not associated with female PDs (P = .79) or URiM PDs (P = .48). Programs with a greater percentage of URiM residents were not associated with URiM PDs (P = .16). Larger programs (P = .021) and university-based programs (P = .048) had a greater percentage of female residents. Orthopaedic residency programs with visa sponsorship had a greater percentage of URiM residents (P = .017). CONCLUSIONS: Programs with a higher percentage of female or URiM residents did not show a significant association with having female or URiM PDs. Larger programs and university-affiliated programs were more likely to have a larger percentage of female residents, whereas programs that offered visa sponsorship had a higher percentage of URiM residents. CLINICAL RELEVANCE: This study highlights factors influencing diversity among orthopaedic surgery residents. Although the presence of female or URiM PDs does not influence the percentage of female or URiM residents, other program characteristics such as size, affiliation, and visa sponsorship offer potentially actionable insights for promoting greater diversity in orthopaedic training. Doing so may increase under-represented groups within the field and could ultimately impact patient care and improve health care equity.

How many sites should an orthopedic trauma prospective multicenter trial have? A marginal analysis of the Major Extremity Trauma Research Consortium completed trials.

BACKGROUND: Multicenter trials in orthopedic trauma are costly, yet crucial to advance the science behind clinical care. The number of sites is a key cost determinant. Each site has a fixed overhead cost, so more sites cost more to the study. However, more sites can reduce total costs by shortening the study duration. We propose to determine the optimal number of sites based on known costs and predictable site enrollment. METHODS: This retrospective marginal analysis utilized administrative and financial data from 12 trials completed by the Major Extremity Trauma Research Consortium. The studies varied in size, design, and clinical focus. Enrollment across the studies ranged from 1054 to 33 patients. Design ranged from an observational study with light data collection to a placebo-controlled, double-blinded, randomized controlled trial. Initial modeling identified the optimal number of sites for each study and sensitivity analyses determined the sensitivity of the model to variation in fixed overhead costs. RESULTS: No study was optimized in terms of the number of participating sites. Excess sites ranged from 2 to 39. Excess costs associated with extra sites ranged from $17K to $330K with a median excess cost of $96K. Excess costs were, on average, 7% of the total study budget. Sensitivity analyses demonstrated that studies with higher overhead costs require more sites to complete the study as quickly as possible. CONCLUSIONS: Our data support that this model may be used by clinical researchers to achieve future study goals in a more cost-effective manner. TRIAL REGISTRATION: Please see Table 1 for individual trial registration numbers and dates of registration.

Implementation of a novel peer review academy by Surgery and the Association of Women Surgeons.

BACKGROUND: A novel Peer Review Academy was developed as a collaborative effort between the Association of Women Surgeons and the journal Surgery to provide formal training in peer review. We aimed to describe the outcomes of this initiative using a mixed methods approach. METHODS: We developed a year-long curriculum with monthly online didactic sessions. Women surgical trainee mentees were paired 1:1 with rotating women surgical faculty mentors for 3 formal peer review opportunities. We analyzed pre-course and post-course surveys to evaluate mentee perceptions of the academy and assessed changes in mentee review quality over time with blinded scoring of unedited reviews. Semi-structured interviews were conducted upon course completion. RESULTS: Ten women surgical faculty mentors and 10 women surgical trainees from across the United States and Canada successfully completed the Peer Review Academy. There were improvements in the mentees' confidence for all domains of peer review evaluated, including overall confidence in peer review, study novelty, study design, analytic approach, and review formatting (all, P ≤ .02). The mean score of peer review quality increased over time (59.2 ± 10.8 vs 76.5 ± 9.4; P = .02). In semi-structured interviews, important elements were emphasized across the Innovation, Implementation Process, and Individuals Domains, including the values of (1) a comprehensive approach to formal peer review education; (2) mentoring relationships between women faculty and resident surgeons; and (3) increasing diversity in the scientific peer review process. CONCLUSION: Our novel Peer Review Academy was feasible on a national scale, resulting in significant qualitative and quantitative improvements in women surgical trainee skillsets, and has the potential to grow and diversify the existing peer review pool.

Finding Your Job in Orthopaedic Trauma: A Survey Revealing the Cold Hard Facts.

OBJECTIVES: Finding a first job after fellowship can be stressful due to the uncertainty about which resources to use, including fellowship program directors, residency faculty, and other sources. There are more than 90 orthopaedic trauma fellows seeking jobs annually. We surveyed orthopaedic trauma fellows to determine the job search process. DESIGN: An anonymous 37-question survey. SETTING: Online Survey. PATIENT SELECTION CRITERIA: Orthopaedic trauma fellows from the 5 fellowship-cycle years of 2016-2021. OUTCOME MEASURES AND COMPARISONS: The primary questions were related to the job search process, current job, and work details. The secondary questions addressed job satisfaction. Data analysis was performed using STATA 17. RESULTS: There were 159 responses (40%). Most of the respondents completed a fellowship at an academic program (84%). Many (50%) took an academic job and 24% were hospital employed. Sixteen percent had a job secured before fellowship and 49% went on 2-3 interviews. Word of mouth was the top resource for finding a job (53%) compared with fellowship program director (46%) and residency faculty (33%). While 82% reported ending up in their first-choice job, 34% of respondents felt they "settled." The number of trauma cases was important (62%), ranked above compensation (52%) as a factor affecting job choice. Surgeons who needed to supplement their practice (46%) did so with primary and revision total joints (37%). CONCLUSIONS: Jobs were most often found by word of mouth. Most fellows landed their first job choice, but still a third of respondents reporting settling on a job. Case volume played a significant role in factors affecting job choice.

National survey results on effect of COVID-19 pandemic on female surgeons: A new normal work environment.

BACKGROUND: The impact of COVID-19 reaches the overall well-being of women surgeons. We aimed to describe the impact of transitioning to a new challenging environment. METHODS: A survey of 60 quantitative questions using a Likert-like scale was distributed electronically via email across 1200 members of the Association of Women Surgeons in 2021. Family lifestyle factors including care for children, elderly family members, extent of household chores, and impact of COVID-19 pandemic were queried. RESULTS: A total of 139 members responded. Fifty one percent of these respondents had children at home and 31.2% indicated they needed additional help at home during that time. Eighteen percent of those in practice cared for their elderly family members. Of the survey participants, 71.2% felt the COVID pandemic resulted in a worsened clinical practice, with 30.9% noting a decrease in income. CONCLUSIONS: Women surgeons faced crucial challenges during and post pandemic. An awareness of the changing needs of women surgeons is essential.

Publication and Career Trends of Ruth Jackson Orthopaedic Society Grant Winners Over the Past Decade.

Background: The Ruth Jackson Orthopaedic Society awards the Jacquelin Perry, MD Resident Research Grant and RJOS/Zimmer Biomet Clinical/Basic Science Research Grant to female orthopedic surgeons, intending to aid women in the progression and completion of their orthopedic research and bolster their pursuit or current career in academic orthopedic surgery. The impact of these grants has not yet been studied. The purpose of this study is to determine the percentage of scholarship/grant-winners who went on to publish the findings of their research, pursue academic positions, and currently hold positions of leadership in the field of orthopedic surgery. Methods: The titles of the winning research projects were searched in PubMed, Embase, and/or Web of Science to ascertain publication status. For each award recipient, the number of publications prior to the award year, number of publications after the award year, total number of publications, and H-index were calculated. Each award recipient was searched online through the websites of their employment and social media pages to determine their residency institution, whether they pursued a fellowship, the number of fellowships they pursued, their subspecialty within orthopedics, their current job, and whether they are in academic or private practice. Results: Of the fifteen Jacquelin Perry, MD Resident Research Grant winners, 73.3% of awarded research projects have since been published. 76.9% of award winners currently work in an academic setting and are affiliated with a residency program, and 0% currently hold leadership positions in orthopedic surgery. Of the eight winners of the RJOS/Zimmer Biomet Clinical/Basic Science Research Grant, 25% have published the findings of their awarded grant. 87.5% of award winners currently work in academics, and 75% hold leadership positions in orthopedic surgery. Conclusion: Our results show that many of the winners of the Jacquelin Perry, MD Resident Research Grant and RJOS/Zimmer Biomet Clinical/ Basic Science Research Grant have published their research findings, continued research within the field of orthopedic surgery, and pursued academic careers and leadership positions. Many of the barriers to career progression and entry into orthopedic surgery that women and underrepresented groups face could be overcome through more grant opportunities and mentorship. Level of Evidence: V.

Trends in Female Authorship in Orthopaedic Literature from 2002 to 2021: An Analysis of 168,451 Authors.

BACKGROUND: Significant gender disparity exists in orthopaedic surgery. While women have increasingly entered the field, we are short of the critical mass needed to drive change, including in authorship. This study aimed to characterize trends in authorship in peer-reviewed orthopaedic journals in the context of gender. METHODS: This is a cross-sectional bibliometric study of orthopaedic journals in the United States. Articles that were indexed in the orthopaedic category of the Clarivate Journal Citation Report (JCR) and the Science Citation Index Expanded (SCIE) were analyzed (n = 82). Journals not originating from the U.S. (n = 43) or not considered primarily orthopaedic journals (n = 13) were excluded. The 2020 impact factors (IFs) of the remaining 26 journals were recorded. The articles underwent automated data collection from PubMed for January 2002 to December 2021 using R software to collect the title, the journal, the publication year, the first and senior author names, and the country of origin. Gender was determined by Gender API ( https://gender-api.com ). Names with <90% accuracy were excluded. RESULTS: Overall, 168,451 names were studied, with 85,845 and 82,606 first and senior authors, respectively. Of the first and senior authors, 13.6% and 9.9%, respectively, were female. The proportion of female first authors was significantly greater than the proportion of female senior authors. The average IF was significantly higher for male authors compared with female authors (p < 0.005). Articles with female first authors were significantly more likely to have a female senior author. Orthopaedic subspecialty journals had a smaller proportion of manuscripts authored by female first and senior authors than general journals (p < 0.0001). There were 4,451 articles written by a single author, of which 92% (4,093) were written by a man and 8% (358) were written by a woman. Over the 20-year study period, the proportion of female first authorship exhibited a significant positive trend; however, there was a non-significant increase in female senior authorship. CONCLUSIONS: Female representation in orthopaedics has been growing over the past decade. Increasing publication rates of female authors reveal steps toward positive gender equity in the field and present an opportunity for female leadership visibility, illustrating the capabilities of women in orthopaedics and encouraging more women to join the field.

Bullying in Orthopaedic Surgery: A Survey of US Orthopaedic Trainees and Attending Surgeons.

INTRODUCTION: Bullying is a notable problem in surgery, creating a hostile environment for surgeons and trainees, and may negatively affect patient care. However, specific details regarding bullying in orthopaedic surgery are lacking. The primary aim of this study was to determine the prevalence and nature of bullying within orthopaedic surgery in the United States. METHODS: A deidentified survey was developed using the survey created by the Royal College of Australasian Surgeons and the validated Negative Acts Questionnaire-Revised survey tool. This survey was distributed to orthopaedic trainees and attending surgeons in April 2021. RESULTS: Of the 105 survey respondents, 60 (60.6%) were trainees and 39 (39.4%) were attending surgeons. Although 21 respondents (24.7%) stated they had been bullied, 16 victims (28.1%) did not seek to address this behavior. Perpetrators of bullying were most commonly male (49/71, 67.2%) and the victims' superior (36/82, 43.9%). Five bullying victims (8.8%) reported the behavior, despite 46 respondents (92.0%) stating that their institution has a specific policy against bullying. CONCLUSION: Bullying behavior occurs in orthopaedic surgery, with perpetrators being most commonly male and the victims' superiors. Despite the fact that an overwhelming majority of institutions have policies against bullying, the reporting of such behavior is lacking.

Are Orthopedic Fellowship Programs Giving Out Too Many Interviews? A Retrospective Analysis Suggests They Are.

Background: The orthopedic surgery fellowship match process is associated with substantial stress and expense, yet the optimal number of interviews for fellowships to offer has not been evaluated. Purpose: We sought to evaluate the number of orthopedic surgery fellowship interviews given and construct a model to determine the appropriate number of interviews to offer based on specialty and program size. Methods: We conducted a retrospective study of 6 orthopedic fellowship specialties; data were obtained from San Francisco Match and covered the 5-year period from 2014 to 2018. The orthopedic fellowship subspecialties included adult reconstruction/oncology, foot and ankle, pediatrics, spine, sports medicine, and trauma. We excluded shoulder and elbow (less than 5 years of data) and hand and upper extremity (alternative matching process). Parameters included number of programs, number of spots per program, number of ranked applicants per program (mean ± SD), and difference in number of interviews offered and ranked applicants per program (mean ± SD). Multiple regression analysis was used to create an equation for determining the optimal number of interviews for the programs. Results: Of 1377 orthopedic fellowship programs analyzed, 1370 (99.50%) conducted interviews beyond the number of ranked applicants. Programs ranked an overall mean of 20.10 ± 10.17 applicants with an overall mean of 11.60 ± 8.62 additional interviews offered. Sports medicine had the highest mean ranked applicants (23.21 ± 9.77) and pediatrics had the lowest mean ranked applicants (15.74 ± 7.76). The most additional interviews were given in adult reconstruction (14.80 ± 9.92) and the least were given in pediatrics (8.32 ± 7.17). The predictive equation was reported as Y = ß1x1 + ß2x2 (Y = ranked applicants, x1 = spots open, and x2 = last rank). Conclusion: Programs in 6 orthopedic subspecialties in the fellowship match process appear to consistently offer more interviews than necessary. We have developed a model to help programs predict the optimal number of fellowship applicants to interview. Future studies need to validate the model, especially with anticipated increases of the virtual interview format.