Orthopedic Surgery Training Programs Research Articles

Foot and ankle fellowship-trained osteopathic orthopaedic surgeons: a review, analysis, and understanding of current trends.

Over the past several decades, orthopedic surgery has seen a substantial increase in the number of surgeons completing fellowship training. Doctors of Osteopathic Medicine (DOs) continue to advance their orthopedic education through subspecialty fellowship training. DOs have represented between approximately 6 % and 15 % of American Orthopaedic Foot and Ankle Society (AOFAS) fellows. Although historical representation has been considered strong, the fellowship match years 2020 and 2021 have seen a decline in osteopathic orthopedic surgeons participating in foot and ankle fellowships. This deviates from the recent trends of increasing participation across orthopedic subspecialities. To investigate and review the trends of orthopedic foot and ankle fellowship training. Data was reviewed from the AOFAS regarding number of fellows matched and degree obtained. Data from the Federation of State Medical Boards (FSMB), American Orthopaedic Foot and Ankle Society (AOFAS) and Association of American Medical Colleges (AAMC) were reviewed for physician trends and match statistics. Fellowship match years 2020 and 2021 have seen a decline in osteopathic orthopedic surgeons participating in foot and ankle fellowships, with only roughly 3% of AOFAS fellows being osteopathic trained. Orthopedic surgery has the highest rate of subspecialty training of all surgical specialties. Although there is hope for an increasing osteopathic presence in orthopedic surgery, recent literature has pointed to potential for continued bias in opportunities for osteopathic students. We hope that increased participation of osteopathic graduates in orthopedic surgery training programs will result in the continued expansion of osteopathic orthopedic surgeons completing fellowship training, including in foot and ankle surgery.

Giving and Receiving Meaningful Feedback in Orthopaedic Surgery Training.

The process of giving and receiving feedback in orthopaedic surgery training programs is distinctly unique from any other job. Trainees are required to meet certain milestones, and faculty are responsible for the caliber of surgical skills of their graduating trainees, yet there are rarely standardized practices and guidance for providing real-time feedback. Furthermore, institutional educational programs for faculty on giving meaningful feedback are lacking. The purpose of this article was to understand how feedback is defined, how to appropriately involve the learner in the process to foster active engagement rather than destructive thinking, and to characterize important principles that can elevate one's learning and self-reflection to the fullest potential.

Match Rates Among Underrepresented Minority and Female Applicants to Orthopaedic Surgery Residency Programs from 2011 to 2021: How Are We Doing?

Orthopaedic surgery residency programs have traditionally had less representation of underrepresented minority (URM) and female trainees compared with other medical specialties. Widespread efforts have been implemented to increase the diversity of orthopaedic surgery residency programs; however, it is not known whether URM and female applicants are increasingly likely to match as a result. Thus, we aimed to study the independent association between URM and female applicants and matching into orthopaedic surgery over the past decade. Applicant-level data from the Electronic Residency Application Service were reviewed from 2011 to 2021 with variables including demographic variables, URM status, and matriculation to an orthopaedic surgery residency program. Multivariate logistic regression was used to identify the likelihood of matriculating into orthopaedic surgery when controlling for number of applications, top 40 medical school status, AOA status, and MD/other degree. Twelve thousand one hundred eleven applicants were identified from 2011 to 2021 with a match rate of 70% overall. Two thousand fifty-six applicants (17%) were female and 1,926 (16%) classified as URM. The total number of applications increased from 1,074 in 2011 to 1,229 in 2021. The adjusted odds ratio (OR) associated with matching among all applicants decreased from 0.75 in 2011 to 0.64 in 2021, p < 0.001, and the OR of non-URM male and female applicants also decreased (female: 0.79-0.69, p < 0.001; male: 0.78-0.65, p < 0.001). The OR of URM male applicants did not change significantly (0.57-0.55, p = 0.60). The OR for URM female applicants, however, increased significantly from 0.46 to 0.61, p < 0.001. Over the entire time frame, the odds of matching were significantly lower for URM applicants compared with non-URM applicants (both male and female). Overall, the adjusted odds ratio of matching into orthopaedic surgery among female URM applicants has increased over the past decade, indicating successful efforts to improve the diversity of orthopaedic surgery training programs. The odds of URM male applicants have remained relatively constant, and the odds of URM male and female applicants were significantly lower than all non-URM applicants. III.

The Effects of COVID-19 on Orthopaedic Surgery Training Programs in the United States

This study investigates the effects of the COVID-19 pandemic on medical education, research opportunities, and mental health in orthopaedic surgical training programs. A survey was sent to the 177 Electronic Residency Application Service-participating orthopaedic surgery training programs. The survey contained 26 questions covering demographics, examinations, research, academic activities, work settings, mental health, and educational communication. Participants were asked to assess their difficulty in performing activities relative to COVID-19. One hundred twenty-two responses were used for data analysis. Difficulties were experienced in collaborating with others (49%), learning through online web platforms (49%), maintaining the attention span of others through online web platforms (75%), and in gaining knowledge as a presenter or participating through online web platforms (56%). Eighty percent reported that managing time to study was the same or easier. There was no reported change in difficulty for performing activities in the clinic, emergency department, or operating room. Most respondents reported greater difficulty in socializing with others (74%), participating in social activities with coresidents (82%), and seeing their family (66%). Coronavirus disease 2019 has had a significant effect on the socialization of orthopaedic surgery trainees. Clinical exposure and engagement were marginally affected for most respondents, whereas academic and research activities were more greatly affected by the transition from in-person to online web platforms. These conclusions merit investigation of support systems for trainees and evaluating best practices moving forward.

Impact of Specialty on Cases Performed During Spine Surgery Training in the United States

Two general pathways exist for spine surgery training in the United States: orthopedic surgery and neurological surgery. Previous studies have not quantified the impact of fellowship training when comparing case volumes between these 2 training pathways. This study compares reported spine surgery case volume upon graduation from orthopedic surgery and neurological surgery training. This was a retrospective cohort study of recent graduates from orthopedic surgery and neurological Surgery training programs in the United States (2018-2021). The Accreditation Council for Graduate Medical Education provided case logs for residents in neurological surgery and orthopedic surgery as well as fellows in orthopedic spine surgery. Case volumes were compared for adult and pediatric spine surgery cases using parametric tests. Case logs from 3146 orthopedic surgery residents, 107 orthopedic spine surgery fellows, and 766 neurological surgery residents were included in this study. Across each cohort, neurological surgery trainees reported more total adult spine surgery cases than orthopedic surgery trainees (514±206 vs. 383±171, P < 0.001). Orthopedic surgery trainees reported more total pediatric spine surgery cases (21±14 vs. 17±12, P= 0.006). Neurological surgery training affords a greater volume of adult spine surgery cases, but orthopedic surgery affords more pediatric spine surgery cases. Identification of relative strengths and weaknesses can help facilitate multidisciplinary training experiences in spine surgery.

Educational and Clinical Outcome Measures in an Integrated Hand Service

BackgroundWe recently sought to integrate our orthopaedic and plastic hand surgeons with the goal of improving education, patient care, and providing seamless, continuous coverage for our trauma center. Our hypothesis was that integration could serve both the orthopaedic and plastic surgery training programs well and provide more consistent care for the trauma patients. Materials and MethodsProgram director approval was granted for blinded analysis of case logs from plastic and orthopaedic surgery programs from 2012 through 2019. Data on mean and total number of hand cases were analyzed and compared for both specialties. Institutional Review Board approval was granted for a retrospective review of patient outcomes. ResultsFor both orthopaedic and plastics resident trainees, the mean number of hand cases increased during this study period suggesting that the integration had a favorable impact on both programs. The mean number of hand cases for orthopaedic residents rose from 163 to 246. The mean number of hand cases for plastic surgery residents rose from 218 to 295. Patient outcomes as reflected in length of stay and time to consultation also improved. ConclusionTo improve hand surgical training and patient care, an integrated orthoplastics approach to hand surgery was implemented at our institution. Plastic surgery trainees are completing more hand surgery cases in an integrated model (p < 0.001), including fracture care (p < 0.047). Orthopaedic surgery trainees have doubled the percentage of integumentary and microsurgery cases in the integrated model (p < 0.001). The educational and clinical changes affected in an integrated model have changed the paradigm for educating future hand surgeons at our institution.

Nth Dimensions Evolution, Impact, and Recommendations for Equity Practices in Orthopaedics.

Women and underrepresented medical students are frequently unable to see, identify, or interact with an orthopaedic surgeon who looks like them. Simultaneously, these students are repeatedly challenged about their aspirations and questioned about their ability to become an orthopaedic surgeon. Ultimately, students from marginalized groups are unable to envision any future role as an orthopaedic surgeon and are actively diverted to other medical specialties. Nth Dimensions has developed programming that provides relatable role models, consistent positive affirmation, hands-on surgical and research experiences, and exposure to a community that expects for the scholars to succeed. In addition, Nth Dimensions has developed a series of best practices, or "steps," designed to help orthopaedic surgery training programs successfully recruit and retain diverse residents and faculty and ensure their success by providing a safe, all-inclusive learning and working environment.

Current Resident and Faculty Mentorship Satisfaction and Important Mentee Functions in Orthopedic Surgery: An American Orthopedic Association North American Traveling Fellowship Project

While mentorship remains important in orthopedic training, few studies have delineated specific priorities for creating successful mentorship programs and reciprocal satisfaction among contemporary trainees and faculty. The purpose of this study was to define beneficial mentor qualities along with specific mentee characteristics to facilitate improved mentoring relationships in orthopedic surgery. This is a cross-sectional study with a 16 multi-item self-reported survey. This study was conducted at 11 tertiary orthopedic surgery training programs during the 2017 American Orthopaedic Association (AOA) North American Traveling Fellowship Tour. Eighty orthopedic resident trainees and 90 academic faculty members completed the survey. Around 55.0% of residents and 48.9% of faculty acknowledged a formal mentorship program at their institution. Furthermore, 61.3% of residents and 61.1% of faculty reported having a current mentor. The top 3 qualities valued by residents were a mentor who modeled work-life balance, remained in touch with contemporary issues in training, and provided timely counseling. Faculty valued a mentor who accepted their goals and priorities, provided counseling, and enhanced exposure in their subspecialty. Surveyed faculty were more satisfied than their corresponding residents with how their mentor promoted them, enhanced their exposure, was a friend, and protected them from exploitative collaborations. Mentee participation was considered the most important variable for a successful mentor relationship, while mentee acknowledgement of their mentors was the least prioritized quality. Faculty had a higher overall satisfaction with their mentoring relationships in orthopedic surgery. Residents reported more favorable results when their mentor was a role model of work-life balance. For optimal success, mentors identified active participation and openness to feedback as the most important quality for a mentee to display. These qualities contribute to a heightened sense of satisfaction among mentors and mentees and can be utilized to further guide development of both formal and informal programs for residents and faculty.

Adapting Orthopaedic Surgery Training Programs During the COVID-19 Pandemic and Future Directions

The COVID-19 pandemic swept across the world, altering the structure and existence of graduate medical education programs across all disciplines. Orthopaedic residency programs can adapt during these unprecedented times to continue providing meaningful education to trainees and to continue providing high-quality patient care, all while keeping both residents and patients safe from disease. The purpose of this review was to evaluate the literature and describe evidence-based changes that can be made in an orthopaedic residency program to ensure patient and resident safety while sustaining the principles of graduate medical education during the COVID-19 pandemic. We describe measures that can be enacted now or during future pandemics, including workforce and occupational modifications, personal protective equipment, telemedicine, online didactic education, resident wellness, return to elective surgery, and factors affecting medical students and fellows. After a review of these strategies, programs can make changes for sustainable improvements and adapt to be ready for second-wave events or future pandemics. Level of EvidenceLevel V.

The current use of Twitter in orthopaedic surgery departments: A cross-sectional analysis

Background: The extent to which individual clinical departments use Twitter™ is largely unknown. Further, impact of use has not been extensively studied. The purpose of this study was to identify and analyze Twitter™ utilization by orthopaedic surgery departments and to gauge the implications Twitter™ use has on the status of the department. Methods: We conducted a cross-sectional analysis of Twitter utilization for all Accreditation Council for Graduate Medical Education (ACGME)-accredited orthopaedic surgery training programs. Tweets between May 1 and December 1, 2018 were categorized and Tweet impact was assessed using public interaction. Program rankings, as measured by Doximity and US News and World Report (USNWR), were correlated with various Twitter variables. Correlations were calculated with Pearson’s correlation coefficient. Results: Of the 153 ACGME-accredited orthopaedic surgery departments, 24 (15.7%) had Twitter accounts. The departments averaged 1079.35±713.47 followers and a mean of 16.16±13.83 tweets per month. Most tweets were internally generated “unique” tweets. Unique tweets had a mean of 4.50±0.04 likes and 1.10±0.12 retweets per tweet. Twitter account profile data and tweet content demonstrated equal numbers of tweets categorized as “educational” and “other”. Both Doximity and USNWR had more favorable ranks with increasing variables of all Twitter categories, and there was a statistically significant correlation between greater number of post “likes” and a higher USNWR score. Conclusions: Twitter is underutilized by orthopaedic surgery departments and has a small correlation with the reputation of the department. Level of Evidence: Level IV.

Academic Productivity of Spine Surgeons at United States Neurological Surgery and Orthopedic Surgery Training Programs

Spinal surgery is taught and practiced within 2 different surgical disciplines, neurological surgery and orthopedic surgery. We have provided a unified analysis of academic productivity measured using the h-index attributable to spine-focused faculty at U.S. residency programs. A total of 278 Accreditation Council for Graduate Medical Education training programs were assessed to identify 923 full-time faculty members with a spinal surgery designation, as defined by spine fellowship training or case volume >75% in spine surgery. The faculty were assessed with respect to academic rank, duration of practice in years, and academic productivity (h-index). The comparison showed a significantly greater mean h-index for neurological spine surgeons. The mean h-index for both disciplines increased significantly as faculty rank increased. Within the academic ranks of assistant and associate professor, neurological spine surgeons had significantly greater mean h-indexes. Neurological spine surgeons had a significantly lower practice duration. At all ranks except for assistant professor, the mean practice duration was not significantly different statistically between the neurological spine and orthopedic spine surgeons. A positive correlation between the h-index and practice duration was found for both spine surgical disciplines. The proportional odds models for neurological and orthopedic spine surgeons were moderately successful at predicting faculty rank according to the h-index. We present a unified view of academic productivity as measured by the h-index among neurosurgical and orthopedic surgery spine faculty, with some noticeable differences. These results can be used for benchmark purposes to assess the relative productivity of its faculty and could be of interest to those pursuing academic opportunities in spine surgery.

Surgical simulation training in orthopedics: current insights.

BackgroundWhile the knowledge required of residents training in orthopedic surgery continues to increase, various factors, including reductions in work hours, have resulted in decreased clinical learning opportunities. Recent work suggests residents graduate from their training programs without sufficient exposure to key procedures. In response, simulation is increasingly being incorporated into training programs to supplement clinical learning. This paper reviews the literature to explore whether skills learned in simulation-based settings results in improved clinical performance in orthopedic surgery trainees.Materials and methodsA scoping review of the literature was conducted to identify papers discussing simulation training in orthopedic surgery. We focused on exploring whether skills learned in simulation transferred effectively to a clinical setting. Experimental studies, systematic reviews, and narrative reviews were included.ResultsA total of 15 studies were included, with 11 review papers and four experimental studies. The review articles reported little evidence regarding the transfer of skills from simulation to the clinical setting, strong evidence that simulator models discriminate among different levels of experience, varied outcome measures among studies, and a need to define competent performance in both simulated and clinical settings. Furthermore, while three out of the four experimental studies demonstrated transfer between the simulated and clinical environments, methodological study design issues were identified.ConclusionOur review identifies weak evidence as to whether skills learned in simulation transfer effectively to clinical practice for orthopedic surgery trainees. Given the increased reliance on simulation, there is an immediate need for comprehensive studies that focus on skill transfer, which will allow simulation to be incorporated effectively into orthopedic surgery training programs.

Clinical Skills and Professionalism: Assessing Orthopaedic Residents With Unannounced Standardized Patients

We developed a series of orthopedic unannounced standardized patient (USP) encounters for the purpose of objective assessment of residents during clinic encounters. Consecutive case-series. NYU-Langone Multi-center Academic University Hospital System. NYU-Langone/Hospital for Joint Diseases Orthopedic Surgery residents; 48 consecutive residents assessed. Four orthopedic cases were developed. USPs presented themselves as patients in outpatient clinics. Residents were evaluated on communication skills (information gathering, relationship development, and education and counseling). USPs globally rated whether they would recommend the resident. Forty-eight USP encounters were completed over a 2-year period. Communication skills items were rated at 51% (±30) "well done." Education and counseling skills were rated as the lowest communication domain at 33% (±33). Residents were globally recommended based on communication skills in 63% of the encounters recommended in 70% of encounters based on both professionalism and medical competence. The USP program has been useful in assessing residents' clinical skills, interpersonal and communications skills, and professionalism. Use of USP in orthopedic surgery training programs can be an objective means for trainee assessment.

Hand Surgery Resources Exceed American Health Literacy.

The National Institutes of Health, American Medical Association, and US National Library of Medicine recommend that educational material for patients be written at a sixth-grade reading level. The purpose of this study is to assess the complexity of hand surgery information on academic plastic and orthopedic surgery websites. An online search was performed for all hand surgery patient education materials provided by institutions with plastic and orthopedic surgery training programs. Readability analyses were conducted using the Flesch-Kincaid Reading Ease, Flesch-Kincaid Grade Level, Simple Measure of Gobbledygook Index, Gunning Fog Score, Automated Readability Index, and Coleman-Liau Index. A 2-tailed z test was used to compare means. Seventy-six institutions with both plastic and orthopedic surgery training programs were identified; 42 had educational material available online. The average readability for all hand-related information was at the 11.92 grade reading level. Information regarding de Quervain tenosynovitis had the highest grade level for all plastic surgery procedures (13.45). Hand arthritis had the highest grade level for all orthopedic surgery procedures (12.82). Ganglion cysts had the lowest grade level for both plastic and orthopedic surgery (10.15 and 11.01, respectively; P = .12). Carpal tunnel release was the most commonly described procedure overall. There were no differences in text complexity among geographic regions. Online patient resources for common hand ailments are too complex for the average patient to understand. Efforts should be made to provide materials at the recommended sixth-grade reading level to improve patient education and improve the physician-patient relationship.

What Provisions Do Orthopaedic Programs Make for Maternity, Paternity, and Adoption Leave?

The process of choosing medical specialty and residency programs is multifaceted. Today's generation of medical students may have an increased interest in work-life balance and time with their families. In considering this factor, medical students may be influenced by policy regarding maternity, paternity, and adoption leave during residency and fellowship training. Current policy among orthopaedic programs regarding maternity, paternity, and adoption leave is not well described. To understand the influence these policies may have on the choices that medical students make in choosing their specialty, the policies must first be better understood. (1) What proportion of orthopaedic programs have formal or unwritten policies regarding maternity, paternity, and adoptive leave? (2) What are the provisions for time away, allotment of time, and makeup options for trainees who take leave? (3) What proportion of orthopaedic programs report utilization of leave, and what proportions of leave are for maternity, paternity, or adoptive reasons? Accredited programs in orthopaedic surgery were identified through the Council of Orthopedic Residency Directors within the American Orthopaedic Association. Current program directors of these accredited programs were surveyed. The survey was emailed to 144 program directors, of which 141 emails were delivered. Responses were received from 45 program directors, representing 31% of programs. The survey focused on maternity, paternity, and adoptive leave, and it consisted of questions designed to explore program policies (formal, unwritten, no policy, or in development), time considerations (amount allowed, allocation of time away, and makeup requirements), and utilization (trainees who took leave and type of leave used). Most respondents have maternity leave policy (formal: 36 of 45 [80%]; unwritten: 17 of 45 [38%]). Sixteen programs (16 of 45 [36%]) reported having both a formal and an unwritten maternity leave policy. Less than half of the programs have paternity leave policy (formal: 22 of 45 [49%]; unwritten: 19 of 45 [42%]), and fewer programs have adoption leave policy (formal: eight of 45 [18%]; unwritten: 11 of 45 [24%]). For programs that have formal or unwritten policies, most programs allow 4 to 6 weeks off (26 of 43 [60%]) with nearly half of programs allocating leave as paid time off (15 of 37 programs [41%]) and nearly half of programs requiring makeup time (17 of 37 [46%]). Many programs reported no utilization of leave by trainees (23 of 36 [61%]); many programs reported utilization by three or fewer residents (11 of 13 [85%]); and among residents who took leave, maternity was the most common reason (maternity: 22 of 36 [61%]; paternity: 11 of 36 [31%]; adoption: three of 36 [8%]). This study highlights the lack of uniformity among orthopaedic surgery residency and training programs regarding approach to maternity, paternity, and adoption leave. Discussion among program directors, perhaps facilitated by the Council of Orthopedic Residency Directors within the American Orthopaedic Association, to align the programs' policy in this arena may provide more transparent and uniform policy for trainees in orthopaedic surgery.

Resident Education Versus Fellowship Training—Conflict or Synergy?

The fundamental mission of graduate medical education is to train young professionals to become future practitioners and academicians. Orthopaedic surgery training programs are primarily directed toward resident education. The subspecialty training of fellows, however, is arguably equally important. Thus, two constituencies that may compete for educational experience, attention, and resources are inherent to many training programs. We developed a survey to explore this issue prior to a symposium on this topic presented at the American Orthopaedic Association (AOA) meeting in June of 2009. Questions concerning the relationship between resident and fellowship education were distributed to orthopaedic residents in their fourth postgraduate year (PGY-4) of training who attended the Resident Leadership Forum at the 2009 AOA meeting. Responses were obtained from seventy-seven resident participants, a number that represents 12% of the total PGY-4 orthopaedic residents in 2009. The same survey was distributed to orthopaedic surgery department chairs, program directors, and fellowship directors across the United States. One hundred sixty-nine of this “faculty” group responded, a number that was 41.6% of the possible total. In the nineteenth century, surgeons generally were self-trained or learned by way of an apprenticeship1. No formal system was in place and few surgeons spent more than one or two years in a hospital setting. In 1889, with the founding of The Johns Hopkins Hospital, Dr. William Halsted transformed surgical training from its loosely organized structure to a university-sponsored, hospital-based model with graduated responsibility that culminated in a period of near autonomy. Formalization of the qualifications requisite of surgical subspecialties soon followed, largely to assure the public of a specialist’s preparation and skill2. The American Board of Orthopaedic Surgery (ABOS) was incorporated on February 4, 1934, and gave its first certification examination in 19353. Oversight of board certification implied the need for …

Women in Orthopaedics—Way Behind the Number Curve

Women now constitute 49% of medical school matriculants1. The percentage of women in orthopaedic surgery training programs has not kept pace with the increase in the number of women medical students. Although the number of female orthopaedic residents has increased and continues to do so slightly over time, the results of the 2008 American Academy of Orthopaedic Surgeons (AAOS) census reveal that only approximately 4% of orthopaedic surgeons responding to the survey are female2. As of the year 2009, all other surgical subspecialties (with the exception of cardiothoracic surgery) had a higher percentage of women than orthopaedic surgery had. The factors that dissuade women from pursuing careers in orthopaedic surgery are not entirely clear. Several investigators have attempted to assess the factors that come into play when women choose a medical specialty career. In the past, lifestyle issues have been cited as a deterrent for women entering surgery and its subspecialties; however, while lifestyle choice may play some role, it is no longer a significant factor in the disparity. It has been noted by several authors that, with the current generation of medical students and residents, lifestyle alone is not more of a deterrent for women than it is for men when choosing a specialty. In fact, Saalwachter et al., in their study examining the needs of both male and female surgical trainees, found that male and female surgical residents, fellows, and trained surgeons identified almost identical training needs and priorities3. Our report summarizes recent research on women in orthopaedic surgery. Women surgeons, in fact, appear to be very satisfied with their career choice4; however; it is apparent that this information needs to be better conveyed to the medical students. Greater exposure to female surgical faculty would help. Neumayer et al. found …

Are Nitrogen-Containing Intravenous Bisphosphonates Implicated in Osteonecrosis of Appendicular Bones and Bones Other Than the Jaws? A Survey and Literature Review

The purpose of this study was to determine the incidence of osteonecrosis of appendicular bones due to nitrogen-containing intravenous bisphosphonates and the incidence of adverse effects in bones other than the jaws. A detailed search of the professional medical and dental literature was conducted. In addition, a questionnaire was mailed to all known orthopedic surgery training programs in the United States. Programs were queried as to clinical findings and other various scenarios. There was a great paucity of literature that addressed the issue. Of the 154 questionnaires mailed, 29 (19%) were returned. Identification was optional; therefore, it was impossible to determine the geographic origin of the returned questionnaires. No orthopedic surgery training program indicated positive findings of osteonecrosis in the long bones due to nitrogen-containing intravenous bisphosphonates. There were rare reports in the literature of osteonecrosis in other areas of the bony skeleton. On the basis of literature searches and national orthopedic questionnaires, there is only a rare incidence of osteonecrosis of the appendicular bones and bones other than the jaws due to nitrogen-containing intravenous bisphosphonates. There were no reports of adverse long bone effects, based on the questionnaires. There were rare reports in the literature.

Editorial: A Paucity of Women Among Residents, Faculty, and Chairpersons in Orthopaedic Surgery

Editorial: A Paucity of Women Among Residents, Faculty, and Chairpersons in Orthopaedic Surgery

Knowledge of Levels of Evidence Criteria in Orthopedic Residents

The purpose of the levels of evidence system is to provide a framework for critical evaluation of orthopedic literature. This rating system is based on guidelines from the Oxford Centre for Evidence-Based Medicine and is currently in use in several orthopedic surgery journals. The purpose of this study was to investigate resident knowledge of the levels of evidence criteria used in classification of clinical articles. Thirty-eight residents from 5 orthopedic surgery training programs, from year-in-training 3 to 5, determined the levels of evidence rating of 10 blinded articles representing all levels of evidence types in the orthopedic literature. Residents were then provided with a levels of evidence information sheet and asked to re-rate each article. The mean percentage correct for the initial rating was 29.5% and for the post-education rating was 41.3%, with significant improvement after levels of evidence education (P<.001). The year-in-training-3 group had the highest mean percentage correct for the average of both tests (46.7%) compared to year-in-training-4 (34.2%) and year-in-training-5 (25.4%). Residents were significantly more accurate scoring therapeutic (41.1% correct pre-levels of evidence; 51.6% post-levels of evidence) than prognostic studies (6.6% correct pre-levels of evidence; 28.9% post-levels of evidence) (P<.001). Residents graded the level of evidence correctly in fewer than half the papers. These findings indicate that resident knowledge of levels of evidence criteria is limited and suggest a need for more education in this area.