Orthopedics

Feature Article 

An Analysis of Trends in National Residency Matching Program Match Data for Orthopedic Surgery

Nicole Rynecki, BA; Ashok Para, BA; Owen Gantz, BA; Daniel Coban, BA; Zachary Gala, BS; Raghav Gupta, BS; Nimer Adeeb, MD; Joseph A. Ippolito, MD; Jeremy Ruskin, MD; Kathleen S. Beebe, MD

Abstract

Due to electronic residency applications, US Medical Licensing Examination Step 1 scores are frequently used by orthopedic surgery program directors to screen applicants. Prospective applicants therefore often use Step 1 scores as a proxy for specialty competitiveness. The goal of this investigation was two-fold: (1) to determine whether trends in Step 1 scores are indicative of trends in competitiveness of orthopedic surgery and (2) to report the characteristics that optimize a US medical student's match success. A retrospective review of published National Resident Matching Program data from 2009 to 2018 was performed for orthopedic surgery residency applicants. Additional data from the Charting Outcomes reports were used for specific analyses of applicant characteristics. From 2009 to 2018, the number of orthopedic surgery residency positions grew at an annual rate of 1.51% (95% confidence interval [CI], 1.37% to 1.64%; P<.001), accommodating the 1.26% (95% CI, 0.63% to 1.90%; P=.006) annual increase in the number of applicants who ranked orthopedic surgery as their preferred specialty choice (only choice or first choice). There were no significant changes in the applicant-to-position ratio (95% CI, −0.85% to 0.37%; P=.483) or the match rate for US seniors who ranked orthopedic surgery as their preferred choice (95% CI, −0.23% to 0.87%; P=.313). Increases in mean Step 1 scores of matched orthopedic surgery applicants parallel national Step 1 growth trends (0.49% vs 0.44%, respectively). Although orthopedic surgery is currently a competitive specialty to match into, this has been the case since 2009. Increasing Step 1 scores of matched applicants is not unique to orthopedic surgery and should not be misinterpreted as a proxy for increasing competitiveness of the specialty. [Orthopedics. 2020;43(6):e616–e622.]

Abstract

Due to electronic residency applications, US Medical Licensing Examination Step 1 scores are frequently used by orthopedic surgery program directors to screen applicants. Prospective applicants therefore often use Step 1 scores as a proxy for specialty competitiveness. The goal of this investigation was two-fold: (1) to determine whether trends in Step 1 scores are indicative of trends in competitiveness of orthopedic surgery and (2) to report the characteristics that optimize a US medical student's match success. A retrospective review of published National Resident Matching Program data from 2009 to 2018 was performed for orthopedic surgery residency applicants. Additional data from the Charting Outcomes reports were used for specific analyses of applicant characteristics. From 2009 to 2018, the number of orthopedic surgery residency positions grew at an annual rate of 1.51% (95% confidence interval [CI], 1.37% to 1.64%; P<.001), accommodating the 1.26% (95% CI, 0.63% to 1.90%; P=.006) annual increase in the number of applicants who ranked orthopedic surgery as their preferred specialty choice (only choice or first choice). There were no significant changes in the applicant-to-position ratio (95% CI, −0.85% to 0.37%; P=.483) or the match rate for US seniors who ranked orthopedic surgery as their preferred choice (95% CI, −0.23% to 0.87%; P=.313). Increases in mean Step 1 scores of matched orthopedic surgery applicants parallel national Step 1 growth trends (0.49% vs 0.44%, respectively). Although orthopedic surgery is currently a competitive specialty to match into, this has been the case since 2009. Increasing Step 1 scores of matched applicants is not unique to orthopedic surgery and should not be misinterpreted as a proxy for increasing competitiveness of the specialty. [Orthopedics. 2020;43(6):e616–e622.]

The “match” refers to a mathematical algorithm developed by the National Residency Matching Program (NRMP) in 1952 to maximize efficiency and fill American Council of Graduate Medical Education (ACGME)- accredited residency positions based on both student and program director preferences. It was adopted by different specialties at various times after its creation. Despite optimizing medical student preferences, certain specialties are more difficult to match into than others, with orthopedic surgery often regarded as one of these more competitive specialties.1–4 As a result, many applicants are applying to an increasing number of programs to increase their likelihood of matching.2,5 This approach has ramifications on both the applicant and the training programs. The economic burden placed on the applicant is significant, especially given that the majority of applicants are full-time medical students with no stable sources of income.2,5,6 The influx of applications has also forced residency programs to institute stricter objective screening strategies based on US Medical Licensing Examination (USMLE) Step 1 and/or Step 2 scores.7–16 The Step 1 score threshold used to stratify applicants has increased in recent years, interpreted by many applicants as an increased competitiveness of the specialty.8,17

In the decade between 2009 and 2018, the number of orthopedic surgery residency programs increased by 14, totaling 171 programs by 2018.18–20 This increased the number of available residency positions from 641 to 742. Additionally, by the year 2020, American Osteopathic Association–accredited residencies are expected to merge and fall under the jurisdiction of the ACGME, further increasing both the number of programs and pool of applicants.21 Therefore, as the numbers of both orthopedic surgery residency programs and prospective applicants continue to grow and the burden of applications on program directors continues to increase, the importance of interpreting recent trends in orthopedic surgery competitiveness becomes clear.

The purpose of this study was twofold: First, the authors aimed to analyze recent orthopedic surgery trends between 2009 and 2018 to quantify objective measures of competitiveness based on applicant to position ratios and match rates. They then trended USMLE Step 1 scores of matched orthopedic surgery applicants with these objective measures of specialty competitiveness to determine whether Step 1 scores are an accurate proxy for specialty competitiveness. Second, the authors aimed to identify characteristics of the US medical students who matched successfully into orthopedic surgery residency programs. Analysis of these objective measures of orthopedic surgery competitiveness and characteristics of successfully matched applicants can inform both prospective applicants and program directors alike. Specifically, for prospective applicants, the latter purpose of this investigation can help with goal setting early in medical school or even in college to bolster match success as a fourth-year medical student.

Materials and Methods

The authors modeled their study methods after those of Dossani et al,22 who investigated trends in the neurosurgery residency match. A retrospective review of published NRMP data available online from 2009 to 2018 was performed for orthopedic surgery residency applicants. The authors used additional data from the Charting Outcomes reports (published by the NRMP only in 2009, 2011, 2014, 2016, and 2018) for specific analyses regarding applicant characteristics. Institutional review board approval was waived for the purposes of this study.

Factors recorded from the NRMP Results and Data: Main Residency Match file included the number of programs available, positions offered, positions filled, positions unfilled, number of graduating US medical student applicants, number of graduating US medical student applicants who matched, and all other matched applicants by category (International Medical Graduates [IMGs], osteopathic graduates, Canadian graduates, and US medical graduates who failed to match). The authors created measures of orthopedic surgery match competitiveness with applicant-to-position ratio (defined as the ratio of the number of US graduating students applying to orthopedic surgery programs as their preferred choice to that of available orthopedic surgery positions), and with match rate (defined as the percentage of matched US medical graduates into orthopedic surgery residency programs of the total number who ranked it as their preferred choice). Orthopedic surgery was deemed an applicant's preferred choice when an orthopedic surgery residency program was ranked first or as the only specialty listed in an applicant's rank list.

To obtain data for applicant characteristics (and subsequent trend analysis), the authors used data from the Charting Outcomes Report in the Match for US Allopathic Seniors. As noted previously, these reports were only published biennially. The authors collected the number of contiguous ranked programs by the applicants (defined as the number of orthopedic surgery programs ranked uninterrupted by the ranking of a program of a different specialty), USMLE Step 1 and Step 2 scores, number of abstracts, presentations, or peer-reviewed manuscripts, percentage of applicants who were Alpha Omega Alpha (AOA) inductees, percentage of students from top 40 National Institutes of Health (NIH)–funded medical schools, and percentage of students with multiple and/or combined (ie, MD/PhD) degrees.

The NRMP categorizes applicants into 2 broad categories: US Allopathic Medical Students and Independents (foreign medical graduates, US osteopathic graduates, and previous US Allopathic graduates [repeat applicants]). Because the Independent category has extensive inherent heterogeneity, the NRMP groups all independent applicants together, rather than dividing them into distinct subgroups. Therefore, it is not possible to obtain data on particular variables (such as USMLE Step 1 and 2 scores, number of publications, etc) for each subgroup of Independent applicants. Consequently, the authors chose to analyze only US Allopathic Medical Student applicant data in this study.

Annual trends in the number of applicants and positions were assessed by modeling yearly figures with an exponential regression and then transforming the regression coefficients to reflect annual rates of change. Significance for these models was reported on the basis of a neutral-growth null hypothesis with alpha=0.05. Comparisons between group means were made using a two-sided Student's t test, again with alpha=0.05. Statistical analysis was performed in R version 3.5.1 (The R Foundation for Statistical Computing, Vienna, Austria).

Results

In the period analyzed from 2009 to 2018, the total number of orthopedic surgery residency programs increased from 157 to 171 (Table 1). This represents an annual growth rate of 0.72% (95% confidence interval [CI], 0.47% to 0.97%; P<.001). As a result, the total number of residency positions increased from 641 to 742, representing an annual growth rate of 1.51% (95% CI, 1.37% to 1.64%; P<.001). The total number of US seniors who ranked orthopedic surgery as their preferred choice increased by 1.26% during this period, from 745 to 839 applicants (95% CI, 0.63% to 1.90%; P=.006). This corresponds with an increase in the number of matched US seniors who ranked orthopedic surgery as their preferred choice, a figure that increased from 587 to 691 and grew by 1.58% annually (95% CI, 1.25% to 1.92%; P<.001). The total number of applicants to orthopedic surgery residency programs increased from 957 to 1017, but no statistically significant growth trend was observed (95% CI, −0.01% to 1.13%; P=.104). The year 2015 saw the greatest number of orthopedic surgery applicants, but that number has since declined. Of note, this number of applicants includes any student who included even a single orthopedic surgery program on their rank list, which explains why it is substantially larger than the number of those who ranked orthopedic surgery as their preferred choice; some students may have ranked multiple different specialties, not just orthopedic surgery.

Growth Trends in Both Orthopedic Surgery Residency Programs and US Medical Student Applicants Between 2009 and 2018

Table 1:

Growth Trends in Both Orthopedic Surgery Residency Programs and US Medical Student Applicants Between 2009 and 2018

There was no statistically significant trend in the applicant to position ratio for graduating US medical students applying to orthopedic surgery residency programs as their preferred medical specialty (95% CI, −0.85% to 0.37%; P=.483) (Table 1). Similarly, there was no significant trend in the match rate for US seniors who ranked orthopedic surgery as their preferred choice (95% CI, −0.23% to 0.87%; P=.313). The match rate for US seniors who ranked orthopedic surgery as their preferred choice ranged from a low of 75.3% in 2016 to a high of 82.4% in 2018. The average USMLE Step 1 score for applicants who successfully matched into orthopedic surgery increased from 238 in 2009 to 248 in 2018, which represents a 0.49% annual increase (95% CI, 0.38% to 0.60%; P=.002) (Table 2).

Characteristics of Graduating US Medical Students Matching in Orthopedic Surgery Compared With Those Matching Across All Specialties

Table 2:

Characteristics of Graduating US Medical Students Matching in Orthopedic Surgery Compared With Those Matching Across All Specialties

From 2009 to 2018, there was 3.70% annual increase in the number of available positions among all specialties (95% CI, 2.49% to 4.93%; P<.001) and a 2.55% annual increase in the number of applicants (95% CI, 2.12% to 2.98%; P<.001). Over this period, there was no statistically significant trend in the applicant-to-position ratio (P=.089). The average USMLE Step 1 score for all matched applicants also increased from 225 to 233, representing a 0.44% annual increase (95% CI, 0.31% to 0.58%; P=.004) (Table 1).

When compared with overall matched applicants in 2018, matched orthopedic surgery applicants, on average, scored 14.2 points higher on the USMLE Step 1. Matched orthopedic surgery residents comprised 23.4% more AOA students and 2.6% fewer MD/PhD students compared with matched students among all specialties. Matched seniors in orthopedic surgery published 5.8 more papers than all other matched seniors. The matched orthopedic surgery seniors and all matched seniors ranked nearly the same number of contiguous programs (12.5 vs 12.3, respectively) and were similarly represented by students from top-40 NIH-funded medical schools (31.9% of students in both groups) (Table 2).

Qualifications of matched and unmatched US seniors who ranked orthopedic surgery as their preferred specialty choice were compared based on data for US seniors in 2018. Matched US seniors had higher average USMLE Step 1 and 2 scores than unmatched seniors, with an average USMLE Step 1 score of 248 and USMLE Step 2 score of 255 in matched seniors, compared with an average USMLE Step 1 score of 240 and USMLE Step 2 score of 246 in unmatched seniors. Matched US seniors were more likely to be members of AOA as well, with 40.4% of matched US seniors being members of AOA, compared with 15.9% of unmatched US seniors being members of AOA. Matched US seniors were also more likely to be graduates of a top-40 NIH-funded medical school, with 31.9% of matched US seniors attending a top-40 NIH-funded medical school, compared with 26.5% of unmatched US seniors attending a top-40 NIH-funded medical school. Matched seniors in orthopedic surgery authored 4.8 more publications than unmatched seniors (11.5 vs 6.7). Notably, a greater proportion of MD/PhD students went unmatched in orthopedic surgery, with MD/PhD students representing 1.4% of matched applicants vs 2.4% of unmatched applicants. Matched US seniors who listed orthopedic surgery as their preferred choice ranked 5.9 more contiguous programs than unmatched applicants (Table 2).

Discussion

Orthopedic surgery is perceived by many applicants as a specialty continually increasing in competitiveness, likely secondary to increasing mean Step 1 scores. The authors aimed to delve deeper into this notion by analyzing match trends in the decade between 2009 and 2018 using objective measures of competitiveness, the applicant-to-position ratio, and the match rate among applicants who ranked orthopedic surgery as their preferred specialty. Between 2009 and 2018, there was a 1.51% yearly increase in the number of orthopedic surgery residency positions available, resulting in a 15.8% increase in positions by 2018. During this same period, there was a 1.26% yearly increase in the number of applicants who ranked orthopedic surgery as their preferred specialty, resulting in a 12.6% total increase in this pool of applicants by 2018. The number of orthopedic surgery applicants who ranked the specialty as their preferred choice who matched also increased annually by a figure of 1.58%. Although there was no growth trend observed in the total number of applicants to orthopedic surgery, this number includes students who may have only included 1 orthopedic surgery program in their rank list. Therefore, a more accurate representation of serious applicants is the number of students who ranked orthopedic surgery as their preferred specialty (ie, their number 1 choice or the only specialty present on their rank list), which is why the authors opted to use this number in calculating applicant-to-position ratios and match rates.

Given similar growth rates in the supply of orthopedic surgery residency positions and demand by applicants who ranked orthopedic surgery as their preferred specialty, it is not surprising that the applicant-to-position ratio (P=.483) and match rate (P=.313) remained stable throughout the decade. No statistically significant increase was present in either of the objective measures of match competitiveness. In fact, the number of applicants ranking orthopedic surgery as their preferred choice who matched grew (1.58% yearly) slightly more quickly than the number of total applicants ranking orthopedic surgery as their preferred choice (1.26% yearly).

The USMLE Step 1 scores are used by many orthopedic surgery residency programs to screen applicants, and the increasing threshold is perceived by many potentially interested applicants as a proxy for competitiveness of the specialty. Although mean Step 1 scores of matched orthopedic surgery applicants have steadily increased since 2008 by a rate of 0.49% yearly, this cannot be evaluated in isolation. Mean Step 1 scores have been increasing among all applicants to all specialties, at an annual growth rate of 0.44%.23,24 In 2009, the mean USMLE Step 1 score for matched applicants in all specialties was 225, and in 2016 it was 233.22 For US applicants who matched into orthopedic surgery, the mean USMLE Step 1 score was 238 in 2009 and 248 in 2018. Therefore, this study makes the important distinction that although matched orthopedic surgery applicants scored an average of 14.2 points higher on the USMLE Step 1 than general applicants into all specialties in 2018, these facts merely indicate that orthopedic surgery is and has been a more competitive specialty than others to match into since 2009. The authors argue that these rising scores of matched applicants do not indicate increases in competitiveness within the field of orthopedic surgery. In fact, the authors argue that based on their objective measures of competitiveness, orthopedic surgery competitiveness has remained stable during the past decade. A similar incremental rise in board examination scores in orthopedic surgery is present across other specialties as well.

Orthopedic surgery's stable competitiveness can partially be attributed to the increases in residency positions adequately meeting the demand of the increased number of applicants ranking orthopedic surgery as their preferred specialty. Competitiveness of a specialty is largely a function of supply and demand, which is why the measures of specialty competitiveness the authors present in this analysis are superior to USMLE Step 1 score trends. USMLE Step 1 scores, AOA membership, and number of publications are already substantially greater in matched applicants in orthopedic surgery than in matched applicants across all specialties. The stability of the level of competitiveness of orthopedic surgery may indicate that the specialty is approaching an asymptote of maximal competitiveness. Those applying to orthopedic surgery are likely aware of the competitiveness of the specialty and have prepared to achieve these necessary academic accolades to become competitive applicants by the time they are fourth-year medical students.

Although programs are striving to become more objective in their evaluation of prospective applicants, each orthopedic applicant is unique and is likely to possess attributes that would make him or her an excellent resident and surgeon.25 On the basis of the findings of this study, the authors recommend that applicants rank at least 12 contiguous programs to increase the likelihood of matching, although the strength of this recommendation is entirely contingent on the strength of the applicant. The authors emphasize the importance of aiming for a goal Step 1 score of 248 and Step 2 score of 255, given that these scores are 8 and 7 points higher, respectively, than the scores of unmatched US seniors. The authors also encourage working to obtain AOA induction, because matched US seniors were almost 3 times as likely to be members of AOA. In 2018, US seniors who matched into orthopedics authored nearly double the publications of US seniors who went unmatched into orthopedics, which highlights the need to get involved in prolific research experiences early in an applicant's medical school career, or even prior to medical school matriculation. There was negligible difference in the proportion of matched and unmatched applicants graduating from top-40 NIH-funded medical schools, making this of lesser importance for prioritization purposes in prospective orthopedic surgery applicants working to maximize their matching likelihood.

There were several limitations to this study. The data analyzed in this study were obtained via NRMP-published documents. Demographics of applicants are not published. As such, these variables cannot be incorporated into the authors' statistical analysis. Furthermore, data are reported as aggregate values, rather than on an individual basis. Therefore, the authors are unable to determine the relative weight each of the credentials discussed. For example, the Charting Outcomes Report in the Match for US Allopathic Seniors does not distinguish whether the student who scored a 260 was also in AOA, had an MD/PhD, and authored 3 manuscripts. In addition, USMLE scores and AOA status are reported every other year. Given that orthopedic surgery joined the NRMP in 2009, the authors have limited (5) data points to date. Also, all non-US medical school graduates are categorized as Independent, which limits the ability to comment on subgroups within this larger category.

Although the objective parameters measured in this study are good indicators of match success, it is much more difficult to measure the applicant characteristics that enabled them to succeed during the application process. Factors that are not measured by this study include clinical performance during third year (number of honors), performance on sub-internships and externships, and strength of letters of recommendation, all previously recognized as key determinants of an applicant's match success.9,26–28 Another subgroup of applicants is reapplicants to orthopedic surgery residency. Although this study was not able to independently analyze this group, previous data indicate that performing either a year of research or an internship at the institution or region of interest may be advantageous to reapplicants.4

Although there are the aforementioned limitations to the current study, the authors believe that this study is beneficial to both the program director and applicant. For program directors, the authors are pleased to provide a clear and concise resource for reporting trends among orthopedic surgery applicants and now current residents. They may use this resource to compare applicants and assess their competitiveness within the overall orthopedic surgery applicant pool. For prospective orthopedic surgery applicants, the authors hope they clearly refute perceived increasing competitiveness in the field due to misplaced interpretations of increasing Step 1 scores. Nonetheless, orthopedic surgery is a highly competitive specialty and has remained as such over the past decade. The authors feel this study helps to illustrate academic parameters that increase likelihood of match success and encourage usage to help with informed goal setting. The authors urge medical students with a possible interest in orthopedic surgery to critically explore the specialty early in their medical school career. In doing so, they allow themselves ample time to seek out appropriate mentors, get involved in research opportunities, and develop successful study habits to obtain competitive USMLE scores and AOA membership to bolster their candidacy for a residency position.

Conclusion

Despite the notion that orthopedic surgery match competitiveness has increased over time, this analysis indicates that its competitiveness has remained stable in the past decade. USMLE Step 1 scores are not an appropriate indicator for assessing competitiveness trends in the specialty. Prospective applicants should not be dissuaded from applying to residency programs in orthopedic surgery, but should rather be encouraged to prepare for the application process early in their medical school careers to optimize parameters indicative of match success such as USMLE Step 1 and 2 scores, AOA membership, and number of publications. Furthermore, due to the competitiveness of the match process, orthopedic surgery applicants should have a low threshold for ranking a program they were interviewed by, especially if that applicant has 12 or fewer interviews.

References

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Growth Trends in Both Orthopedic Surgery Residency Programs and US Medical Student Applicants Between 2009 and 2018

YearOrthopedic SurgeryAll Specialties


No. of ProgramsNo. of PositionsNo. of ApplicantsNo. of Preferred SeniorsaNo. of Preferreda MatchedPreferreda Applicant-to-Position RatioPreferreda Match RateNo. of PositionsNo. of ApplicantsApplicant-to-Position Ratio
201817174210178396911.13182.4%37,10333,1671.119
201716572710138376681.15179.8%35,96928,8491.247
201616371710588636501.20475.3%35,47627,8601.273
201516170310628786631.24975.5%34,90527,2931.279
201416269510328386491.20677.4%34,27026,6781.285
201316369310388256361.19077.1%34,35529,1711.178
201216168210468316411.21877.1%31,35526,7721.171
201115867010138076211.20477.0%30,58923,4211.306
20101596569967815981.19176.6%30,54322,8091.339
20091576419577455871.16278.8%29,89022,4271.333
Annual growth rate (95% confidence interval)0.72% (0.47% to 0.97%)1.51% (1.37% to 1.64%)0.56% (−0.01% to 1.13%)1.26% (0.63% to 1.90%)1.58% (1.25% to 1.92%)−0.24% (−0.85% to 0.37%)0.32% (−0.23% to 0.87%)2.55% (2.12% to 2.98%)3.70% (2.49% to 4.93%)−1.12% (−2.17% to −0.05%)
P<.001b<.001b.104.006b<.001b.483.313<.001b<.001b.088

Characteristics of Graduating US Medical Students Matching in Orthopedic Surgery Compared With Those Matching Across All Specialties

CharacteristicYear

20092011201420162018
Contiguous ranked programs, mean, No.
  Orthopedic surgery matched11.511.512.112.112.5
  Orthopedic surgery unmatched5.65.75.86.86.6
  All matched9.410.411.511.812.3
US Medical Licensing Examination Step 1 score, mean
  Orthopedic surgery matched238240245247248
  Orthopedic surgery unmatched221225231238240
  All matched225226230233233
US Medical Licensing Examination Step 2 score, mean
  Orthopedic surgery matched241245251253255
  Orthopedic surgery unmatched222231238245246
  All matched231235243245246
Abstracts, presentations, and publications, mean, No.
  Orthopedic surgery matched4.14.56.78.211.5
  Orthopedic surgery unmatched2.73.03.94.96.7
  All matched2.83.24.24.75.7
Alpha Omega Alpha students
  Orthopedic surgery matched27.8%27.1%32.2%34.4%40.4%
  Orthopedic surgery unmatched3.8%5.9%3.3%12.2%15.9%
  All matched15.3%15.0%16.0%17.3%17.0%
Students from top-40 National Institutes of Health–funded medical schools
  Orthopedic surgery matched37.0%37.4%33.0%35.7%31.9%
  Orthopedic surgery unmatched24.1%25.8%22.1%23.4%26.5%
  All matched35.0%34.4%32.7%32.1%31.9%
MD/PhD students
  Orthopedic surgery matched2.6%2.4%1.4%2.1%1.4%
  Orthopedic surgery unmatched1.3%1.6%1.1%2.9%2.4%
  All matched4.2%4.4%3.9%4.1%4.0%
Authors

The authors are from the Department of Orthopaedic Surgery (NR, AP, OG, DC, ZG, JAI, JR, KSB) and the Department of Neurological Surgery (RG), Rutgers New Jersey Medical School, Rutgers University, Newark, New Jersey; and the Department of Neurological Surgery (NA), Louisiana State University School of Medicine, Louisiana State University, Shreveport, Louisiana.

The authors have no relevant financial relationships to disclose.

Correspondence should be addressed to: Kathleen S. Beebe, MD, Department of Orthopaedic Surgery, Rutgers New Jersey Medical School, Rutgers University, 140 Bergen St, Ste D1610, Newark, NJ 07103 ( beebeka@njms.rutgers.edu).

Received: July 11, 2019
Accepted: September 30, 2019
Posted Online: September 22, 2020

10.3928/01477447-20200910-03

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