Completion of Multiple Fellowships by Orthopedic Surgeons: Analysis of the American Board of Orthopaedic Surgery Certification Database

Academic productivity correlates with industry earnings in foot and ankle fellowship programs in the United States: A retrospective analysis

BACKGROUND

The study investigates the connection between academic productivity and industry earnings in foot and ankle orthopedic surgery fellowships. Utilizing metrics like the H-index and Open Payments Database (OPD) data, it addresses a gap in understanding the relationship between scholarly achievements and financial outcomes, providing a basis for further exploration in this specialized medical field.

AIM

To elucidate the trends between academic productivity and industry earnings across foot and ankle orthopedic surgery fellowship programs in the United States.

METHODS

This study is a retrospective analysis of the relationship between academic productivity and industry earnings of foot and ankle orthopedic surgery fellowships at an individual faculty and fellowship level. Academic productivity was defined via H-index and recorded from the Scopus website. Industry earnings were recorded from the OPD.

RESULTS

Forty-eight foot and ankle orthopedic surgery fellowships (100% of fellowships) in the United States with a combined total of 165 physicians (95.9% of physicians) were included. Mean individual physician (n = 165) total life-time earnings reported on the OPD website was United States Dollar (USD) 451430.30 ± 1851084.89 (range: USD 25.16-21269249.85; median: USD 27839.80). Mean physician (n = 165) H-index as reported on Scopus is 14.24 ± 12.39 (range: 0-63; median: 11). There was a significant but weak correlation between individual physician H-index and individual physician total life-time earnings (P < 0.001; Spearman's rho = 0.334) and a significant and moderate positive correlation between combined fellowship H-index and total life-time earnings per fellowship (P = 0.004, Spearman's rho = 0.409).

CONCLUSION

There is a significant and positive correlation between academic productivity and industry earnings at foot and ankle orthopedic surgery fellowships in the United States. This observation is true on an individual physician level as well as on a fellowship level.

Trends in ACGME Accreditation of Orthopedic Surgery Fellowship Training

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

Early-Career Sports Medicine Surgeons Perform a Large Volume of Non-Sports Medicine Procedures: American Board of Orthopaedic Surgery (ABOS) Part-II Data Regarding Orthopaedic Surgeons Specializing in Sports Medicine

BACKGROUND

The purpose of this study was to utilize the American Board of Orthopaedic Surgery (ABOS) Part-II Case List database to (1) define the practice patterns of sports medicine-trained ABOS Part- II Oral Examination Candidates and (2) describe the frequency and practice patterns of individuals who are dual fellowship-trained sports medicine candidates.

METHODS

The ABOS Part-II Case List database was utilized to define all cases submitted by 3,298 applicants indicating completion of a sports medicine fellowship between January 1, 2003, and January 1, 2020. Cases were classified by subspecialty category and case type. The frequency and practice patterns of candidates pursuing additional fellowship training (i.e., "dual fellowship-trained") were recorded. Descriptive statistical methods were used to describe the annual and overall procedure volume and candidate case mix. Trends in the relative frequency of cases performed and fellowship training patterns were determined using linear regression analysis.

RESULTS

On average, sports medicine-trained candidates submitted 100.6 cases for review during the 6-month case collection period: 59.0 (58.6%) sports medicine/arthroscopy cases, 29.3 (29.1%) trauma/general cases, 4.5 (4.5%) adult reconstruction cases, and 7.8 (7.8%) "other" cases per candidate. Although candidates performed fewer total (r 2 = 0.84, p < 0.001) and sports medicine/arthroscopy (r 2 = 0.85, p < 0.001) cases over the study period, the proportion of sports medicine/arthroscopy cases did not change over the study period (p = 0.18). Dual fellowship training was indicated by 333 individuals (10.1%). The number of dual fellowship-trained candidates pursuing additional fellowship training in pediatrics and adult reconstruction increased over the study period, and the number of dual fellowship-trained candidates pursuing additional fellowship training in trauma decreased over the study period.

CONCLUSIONS

Early-career sports medicine candidates are likely to perform >40% of cases outside of the sports medicine subspecialty. Sports medicine trainees are increasingly likely to pursue a second fellowship in pediatrics or adult reconstruction.

LEVEL OF EVIDENCE

Therapeutic Level III . See Instructions for Authors for a complete description of levels of evidence.

Orthopaedic Surgery Pediatric Sports Medicine: Characterizing Practice Patterns and Subspecialization

BACKGROUND

Pediatric sports medicine is a new and rapidly growing subspecialty within orthopaedic surgery. However, there is very limited literature on the practice of pediatric sports medicine in North America. Therefore, the purpose of this study was to evaluate and describe the current practice patterns of orthopaedic surgeons specializing in pediatric sports medicine.

METHODS

An online survey was distributed to orthopaedic surgeons specializing in pediatric sports medicine through the Pediatric Research in Sports Medicine Society. The purpose of the survey was to characterize (1) surgeon demographics, (2) the breakdown of different joint specialization, and (3) the specific procedures for joints that the surgeons specialize in.

RESULTS

Responses from 55 orthopaedic surgeons were collected and analyzed. Most respondents considered pediatric sports medicine as the primary focus of their practice (89.1%, n=49/55). The number of fellowships completed was almost evenly split between either a single fellowship (52.7%, n=29/55) or 2 or more (47.3%, n=26/55). The most common combination of fellowships was pediatric orthopaedics and adult sports medicine (32.7%, n=18/55). Most survey respondents had been in practice for <10 years (69.0%, n=38/55) and were affiliated with an academic center (61.8%, n=34/55). On average, 77.5% of the patients treated were <18 years old. The knee joint was the most specialized joint, with 98.2% (n=54/55) respondents reporting that the knee joint constituted ≥25% of their practice. The knee joint constituted a mean of 52.1% of the respondents' overall practice, followed by the shoulder (15.2%), hip (13.9%), ankle (7.5%), elbow (7.1%), and wrist (4.2%).

CONCLUSIONS

Pediatric sports medicine practices are variable and have distinct practice patterns in pediatric, orthopaedic, and adult sports practices. In the current study, most surgeons are less than 10 years into practice, affiliated with academic centers, and have typically completed either 1 or 2 fellowships after residency. Surgeons were most commonly specialized in the knee joint and cared for patients <18 years old.

LEVEL OF EVIDENCE

Level of evidence IV.

Virtual Pediatric Orthopaedic Fellowship Interviews During the Pandemic: What Did the Applicants and Programs Think?

BACKGROUND

The COVID-19 pandemic precluded in-person interviews for the 2020-2021 fellowship application cycle and may impact future interview cycles. No information is available detailing the implications of a virtual format on either the interviewee or the fellowship program.

METHODS

Two surveys regarding the 2020-2021 virtual interview season were developed and distributed by the Pediatric Orthopaedic Society of North America (POSNA) Fellowship Training and Practice Qualifications Committee: one survey for fellowship applicants and one survey for fellowship program directors.

RESULTS

Surveys were completed by 45 pediatric orthopaedic fellowship applicants and 34 fellowship program directors. Nineteen (42.2%) applicants applied to more programs because of the virtual format and 30 (66.7%) applicants accepted more interviews because of the virtual format. Thirty-one (67%) applicants did not feel the virtual interview format negatively affected their match process. Thirty-eight (84.4%) applicants indicated that they saved >$2000 with the virtual format. Approximately half (22/45, 48.5%) of the applicants would keep the fellowship-interview process virtual-even if in-person interviews were possible-whereas 8 (17.8%) applicants would transition back toward in-person interviews.Most program directors utilized online interviews for the first time (n=28, 82.3%) during the 2020-2021 application cycle. Programs interviewed more applicants for the 2020-2021 cycle than in the prior 5 years (19.3 vs. 15.7 applicants, P <0.01), with programs interviewing 10.1 applicants per fellowship position. The majority (n=22, 64.7%) of programs utilized Zoom for the interview platform. Program directors indicated that the applicants were either more accomplished (n=14, 41.2%) or similar in accomplishment (n=20, 58.8%) when compared with the applicants from prior years. Half of the program directors (n=17, 50%) surveyed would utilize virtual interviews next year, even if in-person interviews are possible.

CONCLUSIONS

During the 2020-2021 fellowship application process, interviewees applied to and were interviewed at more programs because of the virtual format, while saving >$2000. In a similar manner, fellowship programs were able to interview a greater number of applicants without adversely impacting the applicant quality. Approximately half of the interviewees and program directors would continue to perform virtual interviews, even if in-person interviews are possible.

LEVEL OF EVIDENCE

Level V.

Primary hip arthroscopy and conversion to total hip arthroplasty: trends and survival analysis in the Medicare population

INTRODUCTION

With limited evidence on national incidences of hip arthroscopy in the elderly population, the current study aims to investigate trends of primary hip arthroscopies being performed in the elderly population, using the US Medicare database, and determine risk factors for conversion to total hip arthroplasty (THA).

METHODS

Medicare Standard Analytic Files were queried using CPT codes to retrieve records of primary hip arthroscopies done for degenerative pathology during 2005-2014. Overall and age-stratified trends in the incidence of hip arthroscopy over time were analysed. Kaplan Meier survival curves were used to assess the overall 2-year conversion rate to a THA. Cox regression analysis was implemented to study risk factors for conversion.

RESULTS

8100 primary hip arthroscopies for degenerative pathology were performed during 2005-2014. There was a 280% increase in overall incidence of arthroscopy. The most commonly performed arthroscopic procedure was for chondroplasty and/or resection of labrum, with 4712 (58.1%) procedures. Around 18.5% patients underwent arthroplasty within 2 years after primary arthroscopy. Following Cox regression an existing diagnosis of osteoarthritis, ages 65-69, ages 70-74, and arthroscopies done in the West were associated with higher risk of conversion to THA within 2 years. Undergoing a repeat arthroscopy was not significantly associated with a higher risk of conversion.

CONCLUSIONS

Despite inconclusive clinical evidence, hip arthroscopies are being increasingly used in patients older than 65 in the Medicare population. We conclude that patients in the age bracket of 65-74 years and with a pre-existing diagnosis of osteoarthritis, arthroscopy should be approached with caution.

Trends in the pursuit of multiple orthopedic surgery fellowships among orthopedic trainees in Saudi Arabia

Background

The increase in the enrollment of orthopedic surgery residents in multiple fellowship programs has gained considerable interest. Different factors may determine the specialty and number of fellowships trainees enroll in. This study aimed to elucidate these factors and determinants among orthopedic trainees.

Methods

This is a descriptive cross-sectional study, which was conducted among orthopedic surgical trainees (residency and fellowship training programs) in Saudi Arabia, between March 2021 and May 2021. The data were obtained through an online anonymous questionnaire aiming to clarify the most influential factors that determine the number of fellowships trainees choose, as well as to compare the choice of single fellowships with those of multiple ones.

Results

Two hundred and fifty orthopedic trainees (201 (80%) males and 49 (20%) females) completed the survey. Among them, 216 (86%) and 34 (14%) were residents and fellows, respectively, and 81% (n = 203) of the trainees preferred multiple fellowship training, and 22% (n = 47) preferred a single fellowship specialty. Notably, the male trainees preferred multiple fellowships to a single one (85% vs. 62%, p-value = 0.001), while the female trainees preferred single fellowships to multiple ones (38% vs. 15%, p-value = 0.001). The expected rate of income (17% vs. 9%), job opportunities in the private sector (17% vs. 9%), and availability and guarantee of jobs (33% vs. 23%) were the most significant factors that influenced the choices of the participants toward enrolling in multiple fellowships (p-values = 0.001, 0.001, and 0.004, respectively).

Conclusions

The study demonstrated that most of the orthopedic trainees in Saudi Arabia prefer the pursuits of multiple fellowship programs. Further, the female trainees preferred single fellowships, whereas the male ones preferred multiple fellowships. The main influencing factors for pursuing multiple fellowships were determined to be private job opportunities, financial gains, and job guarantees.

Research Productivity of Orthopaedic Sports Medicine Fellowship Programs in the United States

Purpose

To survey orthopaedic sports medicine fellowship program directors to determine the current research productivity of both fellows and faculty in Accreditation Council for Graduate Medical Education-accredited orthopaedic sports medicine fellowship programs in the United States.

Methods

An anonymous 18-question survey was distributed via e-mail to all 95 Accreditation Council for Graduate Medical Education-accredited orthopaedic sports medicine fellowship program directors in the United States. Descriptive statistics were used for data analysis. Questions included whether fellows are required to complete a certain number of projects during their fellowship year and whether fellows have protected research time.

Results

Of the programs, 31 (33%) responded to the survey. Twenty-four programs (80%) require fellows to complete 1 to 4 projects. Twenty-one programs (71%) provide 4 to 8 hours of weekly protected research time. Twenty-four programs (77%) publish 1 to 2 manuscripts per fellow during the fellowship. Twenty-two programs (71%) have fellows work on 1 to 2 projects at a time. Annually, 26 programs (84%) give 0 to 5 podium presentations, 24 (80%) present 0 to 5 posters, and 15 (48%) report 0 to 5 publications. Twenty-four programs (77%) have research fellows and/or assistants to help with research. The presence of dedicated research assistants and more than 25 annual fellowship program publications were found to be useful screening data for more than 2 and more than 4 average publications per fellow, respectively.

Conclusions

The research productivity of orthopaedic sports medicine fellowship programs may be an important consideration for applicants. Applicants who desire to be productive in research during their fellowship year should consider programs with dedicated research assistants and/or programs that publish more than 25 times annually.

Clinical Relevance

This is a descriptive epidemiologic study that helps define the research productivity landscape in orthopaedic sports medicine fellowships. A more accurate understanding of sports medicine fellowship research experience may facilitate a better match between a program's research expectations and an applicant's research interests.

The Competitive Orthopaedic Trauma Fellowship Applicant: A Program Director's Perspective

Introduction:

In 2018, orthopaedic trauma had the lowest match rate among orthopaedic subspecialties. The purpose of this study was to determine the importance of factors evaluated by orthopaedic trauma fellowship directors when ranking applicants after the interview.

Methods:

An electronic survey was submitted to fellowship directors and consisted of 16 factors included in a fellowship application. Respondents were asked to rate the importance of these factors for applicants they interviewed on a 1 to 5 Likert scale, with 1 being not at all important and 5 being critical.

Results:

Thirty-seven fellowship directors responded (63.8%). The highest-rated factor was the applicant interview (mean score 4.82), followed by the quality of letters of recommendation (4.69), personal connections made to the applicant (3.89), and potential to be leader (3.86). Fellowship directors at academic programs rated interest in an academic career (P = 0.003), research experience (P = 0.023), and exposure to well-known orthopaedic traumatologists (P = 0.003) higher than their counterparts at private institutions. Programs with more than one fellow rated potential to be a leader higher than programs with one fellow (P = 0.02).

Discussion:

Trainees may use this study when compiling an application to optimize their chances of matching at the program of their choice.

Pediatric Orthopedics: Is One Fellowship Enough?

Dual-fellowship-trained surgeons specializing in both pediatric and sport medicine are treating an increasing number of pediatric orthopedic injuries, making pediatric orthopedic sports medicine a potential new emerging subspecialty. With fellowship training now being the norm rather than the exception across orthopedics, it is possible that dual-fellowship training may become a prerequisite for treatment of pediatric sports medicine patients. This may impact the practices of surgeons trained in either pediatric or sports medicine alone. As the trend toward dual-fellowship training is likely to continue, future studies are needed to characterize the impact it has on patient care and training patterns.

The Cost of Getting in: Is It Time for Change in the Adult Reconstruction Fellowship Application Process?

Background

The number of applicants to adult reconstruction fellowships (ARFs) has increased significantly in recent years, making the application process increasingly competitive. With this, applicants are applying to and interviewing at more programs which has inherent cost and time implications. The purpose of this study was to assess these implications as well as investigate applicant attitudes toward proposed changes.

Methods

This is a cross-sectional survey study of 2019 and 2020 ARF applicants (n = 278) to a single institution. A 10-question survey was distributed to applicants regarding the application and interview process. This survey focused on application and interview volumes, financial and temporal commitments, as well as perceptions regarding potential application process changes. Descriptive statistics and chi-squared analysis were then performed.

Results

Of the 110 (40%) respondents, 87% spent >$3000 and 43% spent >$5000 during the application process. Most respondents applied to ≥26 programs (84%) and both received and attended ≥11 interviews (87% and 74.5%, respectively). Applicants missed significant training time for interviews (99% missed at least 1 week, 62% two weeks, and 15% three weeks). Attending more interviews (P = .001) and multiple visits to the same city (P = .049) were associated with spending >$5000. Most applicants (72%) felt change to the process would be beneficial.

Conclusions

Applicants to ARF are applying to and interviewing at many programs resulting in significant time away from training and financial investment. Most applicants feel that a change to the system would be beneficial, although no consensus on the best solution was delineated. These data should be considered during the continued evaluation of the match process.

Eponyms in Pediatric Sports Medicine: A Historical Review

The use of eponyms in the orthopedics literature has come under scrutiny, and there is a growing body of literature evaluating the utility of these terms in modern healthcare delivery. Although the field of pediatric orthopedic sports medicine is a relatively modern subspecialty, it is built on a foundation of over 100 years of pediatric musculoskeletal medicine. As a result, eponyms account for a significant portion of the vernacular used in the field. The purpose of this review is to summarize and describe the history of common eponyms relevant to pediatric sports pathology, examination maneuvers, classification systems, and surgical procedures. Use of eponyms in medicine is flawed. However, an improved understanding of these terms allows for informed use in future scientific discourse, patient care and medical education and may encourage future innovation and research into understanding pediatric orthopedic pathologies.

Correlates of Google Search Rankings for Spine Surgeons: An Analysis of Academic Pedigree, Social Media Presence, and Patient Ratings

STUDY DESIGN

Prospective observational study.

OBJECTIVE

The objective of this study is to identify correlates of search ranking among academic pedigree, online ratings, and social media following.

SUMMARY OF BACKGROUND DATA

Patients increasingly rely on online search in selecting healthcare providers. When choosing a spine surgeon, patients typically value surgical skill and experience as well as demeanor/bedside manner. It is unclear whether current search engine ranking algorithms reflect these preferences.

METHODS

A Google.com search for the top 25 spine surgeon websites by search ranking was conducted for each of the largest 25 American cities. Resulting websites were then perused for academic pedigree, experience, and practice characteristics. Surgeons' research output and impact were then quantified via number of publications and H-index. Online ratings and followers in various social media outlets were also noted. These variables were assessed as possible correlates of search ranking via linear regression and multivariate analyses of variance.

RESULTS

A total of 625 surgeons were included. Three categorical variables were identified as significant correlates of higher mean Google search ranking-orthopedics (vs. neurosurgery) as a surgical specialty (P = 0.023), board certification (P = 0.024), and graduation from a top 40 residency program (P = 0.046). Although the majority of the identified surgeons received an allopathic medical education, there was no significant difference in the mean rank of surgeons who had an MD versus DO medical degree (P = 0.530). Additionally, none of the continuous variables collected, including years in practice (P = 0.947), publications (P = 0.527), H-index (P = 0.278), social media following such as on Facebook (P = 0.105), or online ratings such as on Healthgrades (P = 0.080), were significant correlates of Google search ranking.

CONCLUSIONS

Google search rankings do not always align with patient preferences, currently promoting orthopedic over neurosurgical specialists, graduation from top residency programs, and board certification, while largely ignoring academic pedigree, research, social media presence, and online ratings.

LEVEL OF EVIDENCE

3.

Residency Program Reputation Influences the American Association of Hip and Knee Surgeons Match Results

BACKGROUND

No data evaluate the impact that an applicant's residency program reputation has on the outcome of the American Association of Hip and Knee Surgeons (AAHKS) fellowship match. This study sought to determine if an applicant's residency program ranking was associated with where the applicant matched on their rank list.

METHODS

We included all the US applicants from the "San Francisco Match" regarding AAHKS applicant data and match results from 2014 to 2018. Residency programs were divided into 5 tiers based on 2018 Doximity ranking of Orthopedic Residency Programs. Statistical analysis consisted of descriptive statistics, chi-squared tests, and analysis of variance.

RESULTS

In total, 656 applicants met inclusion criteria (620 males; 36 females). Tier 1 applicants applied to an average of 10 fewer programs than applicants from all other tiers. Eighteen percent of applicants from tier 1 residencies were offered interviews at 80%+ of their applied programs compared to 5% or less of the applicants from all other tiers. Applicants from top tier residencies matched at a significantly higher place on their rank list than other tiers (P < .05) and ranked into one of their first 2 choices 72% of the time. The mean fellowship rank position for tier 1 applicants was 5.96 compared to 7.04, 7.85, 7.78, and 8.10 for subsequent tiers, respectively (P < .05).

CONCLUSION

The fellowship match process represents a high-stakes and expensive process. This study found that applicants from more prestigious residency programs apply to fewer programs, gain more interviews, and match higher on their rank list than applicants from other residency programs.

Medicare Compensation Rates for Hand and Shoulder/Elbow Surgery by Operative Time: A Comparative Analysis

Background

There is a high demand for shoulder/elbow experience among hand-fellowship trainees due to the perception that this exposure will improve their professional "marketability" in a subspecialty they perceive as having higher compensation.

Methods

Using Medicare data, we investigated the most common surgeries from these fields and determined which have the highest compensation [work relative value unit (wRVU), payment, charge, and reimbursement (payment-to-charge percentage] rates per operative time. We then determined whether the overall non-weighted and weighted (by surgical frequency/volume) compensation rates of shoulder/elbow surgery are greater than that of hand surgery.

Results

Among 30 shoulder/elbow procedures, arthroplasty and arthroscopic rotator cuff repair had the highest payment and wRVU assignments. Among 83 hand procedures, upper-extremity flaps, carpal stabilization, distal radius open reduction internal fixation (ORIF), both-bone ORIF, and interposition arthroplasty had the greatest wRVU assignments with correspondingly high payments. A non-weighted comparison of the two subspecialties showed that hand surgery has a higher mean payment/min ($10.46±3.22 vs. $7.52±2.89), charge/min ($51.02±17.11 vs. $41.96±11.32), and reimbursement (21±4.7% vs. 18±5.1%) compared with shoulder/elbow surgery (all, P<0.01). Non-weighted mean wRVUs/min were similar (0.12±0.03 vs. 0.13±0.03, P = 0.12). When weighted by procedure frequency, hand surgery had greater wRVUs/min (0.15±0.036 vs. 0.13±0.032), payments/min ($14.17±4.50 vs. $6.97±2.26), charges/min ($75.68±30.47 vs. $42.61±7.83), and reimbursement (20±5.0% vs. 17±6.0%) (all, P<0.01).

Conclusion

According to Medicare compensation, and when weighted by procedure frequency, hand procedures are associated with greater overall mean wRVUs/min, payments/min, charges/min, and reimbursement compared with shoulder and elbow procedures. Hand-surgery fellowship applicants should be aware that subspecialty compensation is complex in nature but should seek shoulder/elbow elective experience to acquire an additional surgical skill-set as opposed to primarily monetary reason.

How the Reputation of Orthopaedic Residency Programs Is Associated with Orthopaedic Fellowship Match Results

BACKGROUND

The primary goal of the present study was to determine if applicants from higher-ranking U.S. orthopaedic surgery residency programs match at a more desired position on their fellowship match-rank list compared with those applicants from lower-ranked residency programs.

METHODS

San Francisco Match provided results regarding applicant data and match results from 2014 to 2018 for all orthopaedic subspecialties except the hand and the shoulder and elbow. Unmatched applicants and international medical graduates were excluded. Residency programs were divided into 5 tiers (with tier 1 being the highest-ranked residency programs and tier 5 being the lowest-ranked programs) on the basis of 2018 Doximity rankings of orthopaedic residency programs. Statistical analysis consisted of descriptive statistics, chi-square tests, and analysis of variance.

RESULTS

Two thousand eight hundred and eleven applicants met inclusion criteria. Applicants from residency programs in tiers 1 and 2 applied to significantly fewer programs than those from tiers 3, 4, or 5 (p < 0.0001). Applicants from each tier were significantly more likely to attain interviews than applicants from all tiers below them (p < 0.01). Applicants from tier-1 residency programs matched at a significantly higher position on their rank list (p < 0.001) and were more desirably ranked by fellowship programs (p = 0.003) compared with all other tiers.

CONCLUSIONS

Applicants from the highest-ranking residency programs apply to fewer programs, interview at a greater percentage of these programs, and are more likely to match to 1 of their top-ranking programs than applicants from lower-ranking programs. However, the association of the applicant match position with the program ranking appears to be most pronounced when it comes to fellowships selecting which applicants to interview. These findings may help future applicants when determining which programs to apply to during the match.

Pediatric Orthopedic Workforce: A Review of Recent Trends

Pediatric orthopedic surgery has changed in many ways over the past 2 decades. Member surveys and recent literature confirm that there has been a sustained balance of interest and opportunity in growth of applicant numbers and fellowship spots. Pediatric orthopedics is leading the way in gender diversity in orthopedics. Concerns of competition are valid and appear to be rising; however, case load data suggest that with increased training of pediatric orthopedists, there seems to be an adequate increase in cases. Periodic workforce analysis should continue to gauge any changes in attitudes or monitor concerns of competition.

Computer Simulation and Maxillary All-on-Four Surgery

Maxillary all-on-four implant reconstruction requires training beyond normal dental implant training. It conjoins technical surgical acumen, anatomic and complex spatial relationship understanding, thorough awareness of dental prosthodontic principles, and excellent patient management skills. Acquisition of appropriate training to the level of competence in an era of greater patient expectations and increased vigilance for patient safety and overall quality of care is limited. Repeated purposeful practice in performing complex psychomotor tasks is of paramount importance in achieving competence. Surgical simulation may assist surgical learners to acquire familiarity with relevant anatomic variations, instrumentation, surgical techniques, and management of intraoperative and postoperative complications.

Improving Complex Pediatric and Adult Spine Care While Embracing the Value Equation

INTRODUCTION

Value in health care is defined as the quotient of outcomes to cost. Both pediatric and adult spinal deformity surgeries are among the most expensive procedures offered today. With high variability in both outcomes and costs in spine surgery today, surgeons will be expected to consider long-term cost effectiveness when comparing treatment options.

METHODS

We summarize various methods by which value can be increased in complex spine surgery, both through the improvement of outcomes and the reduction of cost. These methods center around standardization, team-based and collaborative approaches, rigorous outcomes tracking through dashboards and registries, and continuous process improvement.

RESULTS

This manuscript reviews the expert opinion of leading spine specialists on the improvement of safety, quality and improvement of value of pediatric and adult spinal surgery.

CONCLUSION

Without surgeon leadership in this arena, suboptimal solutions may result from the isolated intervention of regulatory bodies or payer groups. The cooperative development of standardized, team-based approaches in complex spine surgery will lead to the high-quality, high-value care for patients.

Pediatric Sports Medicine, A New Subspeciality in Orthopedics: An Analysis of the Surgical Volume of Candidates for the American Board of Orthopaedic Surgery Part II Certification Exam Over the Past Decade

BACKGROUND

Pediatric orthopaedic surgery has become increasingly subspecialized over the past decade. The purpose of this study was to analyze the volume of pediatric sports medicine cases performed by surgeons applying for the American Board of Orthopaedic Surgeons (ABOS) Part II certification exam over the past decade, comparing caseloads according to the type(s) of fellowship completed.

METHODS

The ABOS database was reviewed for all surgeons applying for the ABOS Part II certification exam from 2004 to 2014. Fellowship training of the candidates was recorded as Pediatrics, Sports, and Dual-Fellowship (fellowship in both Pediatrics and Sports). All other candidates were categorized as "Other". A total of 102,424 pediatric cases (patients below 18 years) were reviewed to identify sports medicine cases performed by CPT code. Multiple linear regression and Mann-Whitney U tests were used to determine trends in case volume overall and according to fellowship training for all patients, patients ≥13 and patients <13. One-way ANOVA testing was used to compare multiple means followed by multiple post hoc comparisons using a Tukey all pairwise approach using SPSS.

RESULTS

A total of 14,636 pediatric sports medicine cases were performed. There was an increase in the number of sports medicine cases performed in patients <13 (117.5±31.8 from 2004-2009 to 212.4±70.1 from 2010-2014, P=0.035; r=0.743, P=0.0007). The number of Pediatrics (r=0.601, P=0.005), Sports (r=0.741, P=0.0007) and Dual-Fellowship candidates increased (r=0.600, P=0.005) from 2004-2014. Dual-Fellowship surgeons performed 21.4% of pediatric sports medicine cases in 2014 when compared to 2.1% in 2004 (919% increase). As a group, the number of pediatric sports cases performed by Dual-Fellowship (r=0.630, P=0.004) and Sports (r=0.567, P=0.007) candidates has increased, while the number performed by "Other" candidates has decreased (r=0.758, P=0.0005). Per surgeon, Dual-Fellowship candidates performed a greater number of pediatric sports cases per collection period (36.5±9.18) than Pediatrics (6.71±0.94), Sports (5.99±0.46), and "Other" (1.21±0.15, P<0.0001 for each) candidates from 2004 to 2014.

CONCLUSIONS

Over the past decade operative sports injuries have increased in children with a similar increase in the number of orthopedic surgeons specializing in pediatric sports medicine. On a per surgeon basis, these dual fellowship-trained candidates have performed on average five times the number of pediatric sports medicine cases compared to all other ABOS Part II candidates. These trends may point towards the development of a new subspecialty of pediatric sports medicine among orthopedic surgeons.

LEVEL OF EVIDENCE

Level IV-Retrospective Database Review.

Trends in the Orthopaedic Surgery Subspecialty Fellowship Match: Assessment of 2010 to 2017 Applicant and Program Data

BACKGROUND

Orthopaedic surgery has become increasingly specialized, and most trainees currently complete subspecialty fellowship training. The purposes of this investigation were to evaluate recent trends in U.S. orthopaedic fellowship matches and to provide relevant analyses for future orthopaedic fellowship applicants and fellowship program directors.

METHODS

This study analyzed data from orthopaedic fellowship match programs from 2010 to 2017. For each fellowship, the following variables were analyzed: numbers of positions offered, participating programs, applicant registrations, rank lists submitted by applicants (i.e., completed applications), applicants matched, and filled positions. Applicant-matching success rate and percentage of total fellowship positions filled for each subspecialty were calculated, and trends were evaluated for significance and difference between subspecialties utilizing ordinary least-square regressions, with p < 0.05 indicating significance.

RESULTS

From 2010 to 2017, the number of fellowship positions that were offered increased in all subspecialties (p < 0.05) except for spine (p = 0.44) and trauma (p = 0.92). Participating fellowship programs increased in all subspecialties (p < 0.05) except spine (p = 0.38) and sports medicine; the latter experienced the only significant decrease (p < 0.05). The largest significant increases (p < 0.05) in both applicant registrations (33.5%) and rank lists submitted by applicants (45.3%) were in adult reconstruction. The subspecialty with the highest applicant-matching success rate during the study period of 2010 to 2017 was sports (mean, 93.5%). Spine and trauma had the lowest applicant-matching success rates in 2016 to 2017. The percentage of positions filled across all subspecialties increased from 2011 to 2017 (p < 0.05); hand had the highest mean (96.6% filled), and adult reconstruction had the largest significant increase from 82.0% in 2010 to 95.5% in 2017 (p < 0.05).

CONCLUSIONS

This investigation provides data with regard to current trends in the orthopaedic fellowship match. Specifically, adult reconstruction fellowship training has recently gained popularity at a more rapid rate than the other subspecialty fellowship pathways, although hand surgery consistently maintains a very high rate of positions filled. Our results for orthopaedic subspecialty fellowship match trends may assist fellowship directors with program planning and career advising and may also assist current residents with fellowship application expectations and career planning.

Subspecialty Training Among Graduates of Pediatric Orthopaedic Fellowships: An 11-Year Analysis of the Database of American Board of Orthopaedic Surgery

BACKGROUND

The field of pediatric orthopaedic surgery is evolving with a reported increase in the number of pediatric orthopaedic fellows being trained as well as an increase in the number of fellows completing additional fellowship training in another subspecialty. The purpose of this study was to examine the historic trends of trainees seeking multiple fellowships within pediatric orthopaedics over an 11-year period using the database of the American Board of Orthopaedic Surgery (ABOS).

METHODS

We queried the ABOS database for fellowship choice of applicants for the ABOS part II oral examination with the self-declared subspecialty of pediatric orthopaedics during the years of 2005 to 2015. Descriptive analysis was performed to determine the percentage of applicants who completed >1 fellowship, and the type of subspecialty fellowship completed. χ analysis was used to compare the proportion of multiple fellowship trainees between years.

RESULTS

From 2005 to 2015, 310 applicants for ABOS part II pediatric subspecialty examination had completed a fellowship in pediatric orthopaedic surgery, with that number increasing from 14 to 43/y over that span. Forty-five trainees (15%) completed 48 additional fellowships over that decade, with 2 recent trainees completing multiple additional fellowships. The most common additional fellowships were sports (n=22, 46%), hand (n=8, 17%), and spine (n=7, 15%). The rate of additional fellowship training increased over 5-fold from 5% in the first 3 years of the study to 28% in the last 2 years of the study (P=0.001).

CONCLUSIONS

The proportion of trainees completing additional subspecialty fellowships in addition to pediatric orthopaedics has risen over the past decade. The precise cause and effect of such change is uncertain and likely multifactorial. Reexamination of our classic training paradigms may be warranted in light of these trends.

LEVEL OF EVIDENCE

Level III.