Orthopaedic Research Consortiums: A Review of Scope, Sex and Racial Representation

Introduction The creation of research groups and consortiums has become more common in all medical and surgical specialities. The purpose of this investigation was to assess and describe collaborative research groups and consortiums within orthopaedic surgery. In addition, we aimed to define the demographics of the research consortium members with particular attention to female and minority members. Methods Journals with a musculoskeletal/orthopaedic focus and a few medical journals were selected to identify articles published by research groups and consortiums. Articles published from 2020 to 2022 were manually reviewed. Bibliographic information, author information and level of evidence (LOE) were recorded. For identified consortium members, sex and race were defined in a binary manner. Results A total of 92 research consortiums were identified. A list of members was identified for 77 groups (83.7%), totalling 2,260 researchers. The remaining group members were not able to be identified due to the lack of information in the included publications, research group websites or after communicating with the corresponding author for respective articles. Most researchers were male (n=1,748, 77.3%) and white (n=1,694, 75%). Orthopaedic surgeons comprised 1,613 (71.4%) identified researchers. The most common fellowship training for orthopaedic surgeons was paediatrics (n=370, 16.4%), trauma (n=266, 11.8%) and sports medicine (n=229, 10.1%). The consortiums published 261 articles: women were lead (first) authors in 23% and senior (last) authors in 11.1%. Non-white researchers were lead authors in 24.5% (n=64) and senior authors in 17.2% (n=45). The most common level of evidence was level 3, accounting for 45.6% (n=119) of all publications. Level 1 evidence accounted for 12.6% (n=33) of published articles. Discussion Representation of women in orthopaedic research consortiums exceeds their representation in almost every orthopaedic professional society. There is less publicly available data to compare the involvement of under-represented minorities (URMs) in research consortiums to general practice. Further investigations should analyse possible avenues in which gender and racial disparity could be improved within orthopaedic surgery research.


Introduction
The creation of research groups and consortiums has become more common in all medical and surgical specialities.The purpose of this investigation was to assess and describe collaborative research groups and consortiums within orthopaedic surgery.In addition, we aimed to define the demographics of the research consortium members with particular attention to female and minority members.

Introduction
The creation of research groups and consortiums has become more common in all medical and surgical specialities.These groups often function to align research interests and resources to produce large-scale, high-quality investigations.Incorporating multiple surgeons at high-volume centres can allow for adequate sample sizes to conduct prospective, randomized clinical trials or larger clinical series of rarer clinical entities.With collaboration between higher-and lower-income countries, research consortiums may also help establish sustainable services in lower-income countries [1,2].Within orthopaedic surgery, the Multicenter Orthopaedic Outcomes Network (MOON) group remains among the most well-known.Originally consisting of three surgeons from two academic centres, the MOON group has expanded to include 19 surgeons at seven institutions since being founded in 2002 [3].At present, this group has enrolled over 4,400 anterior cruciate ligament (ACL) reconstructions into a large prospective database and has conducted multiple level I studies that have been incorporated into clinical practice guidelines [4].Similar collaborative efforts from other groups have resulted in large, clinically impactful randomized controlled trials (RCTs) [5,6].Given the potential impact of collaborative consortiums, there may be opportunities for grant funding, academic advancement and career development for involved collaborators.
Although publications from research groups and consortiums continue to emerge, little is known regarding the origins of these groups.Like-minded colleagues from different academic centres may elect to formally collaborate to answer questions that require large sample sizes; however, the organization, requirements for participation and group structure often remain unclear.During the time that these groups have proliferated in the orthopaedic community, there has been increased recognition of the substantial lack of diversity in orthopaedics [7].For example, multiple prior investigations have found that women are under-represented in podium presentations, leadership roles and as lead/senior authors in peer-reviewed publications [8][9][10][11].
Recently, major orthopaedic professional organizations have recognized the concerning lack of diversity in the field and have made formalized, structured efforts to enhance diversity, equity and inclusion.In 2019, the American Academy of Orthopaedic Surgeons (AAOS) created a five-year strategic plan aimed at increasing diversity among members and within leadership positions [12].There have also been efforts from multiple subspecialty societies including the American Association of Hip and Knee Surgeons (AAHKS), the American Society for Surgery of the Hand (ASSH) and the North American Spine Society (NASS) [13][14][15].These formal initiatives have appeared to have an early effect on enhancing diversity within orthopaedic surgery [9,11,16,17].However, many research groups and consortiums exist outside of professional society oversight, and the demographics of group members remain uncertain.
The purpose of this investigation was to assess and describe collaborative research groups and consortiums within orthopaedic surgery.Research consortiums were chosen as the focus of the study, as there is no prior research dedicated to defining these groups in orthopaedics.In addition, we aimed to define the demographics of the research consortium members with particular attention to female and underrepresented minority (URM) members.We hypothesized that female and URM involvement in these consortiums would be about equal to their representation in overall orthopaedic practice.

Materials And Methods
Institutional review board approval was not required for this study, which did not involve human subjects and utilized publicly available data.We defined research consortiums as named research groups with multiple members.There were no restrictions on the number of involved institutions.Journals were identified using the Scimago Journal Rankings where the included journals were selected via using the "Medicine" and "Orthopaedics and Sports Medicine" subject areas.No limitations were used for region/country selection to capture the widest possible selection of journals.High-impact medical and orthopaedic surgery journals that were not initially identified by this search were also manually selected to identify articles published by research consortiums.These journals were selected to cover general orthopaedic journals with the highest impact factors and the most prominent journal for each orthopaedic subspeciality as well as medical journals where high-impact articles related to orthopaedics are published.A list of the included journals can be found in Table 1.
Once member lists were compiled, we recorded basic demographic information including race and sex in binary categories (white vs. non-white for race and male vs. female for sex) using a previously defined methodology [16,17].For instances in which sex could not be determined manually, "gender-api" was used which has previously been shown to be >97% accurate in identifying sex based on names [19,20].If race or sex could not be defined, no distinction was made.Institutional affiliation and fellowship training were also recorded for each identified consortium member.

Statistical analysis
Descriptive statistics were utilized for this study.Categorical data was reported as count with frequency.A Chi-squared test (or Fisher's Exact test, where appropriate) was conducted for categorical data, and student t-test was used for continuous data, where applicable.All statistical analysis was conducted using SPSS version 28.0.0.0 (IBM Corp., Armonk, NY).

Results
A total of 92 research consortiums were identified.A list of the consortiums can be found in Table 2

TABLE 3: Fellowship and background information of the identified orthopaedic surgeons in the study
The identified research consortiums published 261 articles during the study period; bibliographic information of these studies including the level of evidence, publication topic, journal of publication and institutions representing the most members is included in Table 4. Overall, women were the lead authors in 23% (n=60) and senior authors in 11.1% (n=29) of publications.Demographic information of the identified authors can be found in Table 5.    4).Level 1 evidence accounted for 12.6% (n=33) of published articles.The most common subspecialty topics were spine (n=105, 40.2%), trauma (n=41, 15.7%) and adult reconstruction (n=27, 10.3%) (Table 4).Comparisons between the percentage of female and URM members of the identified orthopaedic research consortiums to orthopaedic professional societies are shown in Table 6.

Discussion
In agreement with our hypothesis, when comparing female representation in orthopaedic research consortiums to that of general orthopaedic practice, their involvement appears more favourable.Our data indicated that 18% of identified consortium members were female.According to the 2018 AAOS Census, only 6% of practising orthopaedic surgeons are female, with 14% identifying as a racial minority [7].While women in orthopaedics remain under-represented relative to the proportion of women in medical school and the general population, our results indicate that the representation of female surgeons in orthopaedic consortiums exceeds their representation in almost every orthopaedic professional society [21,24,25,27,28].Similarly, women account for 18% of all faculty positions and 19% of orthopaedic society leadership positions, which also outpaces the recent AAOS census demographic breakdown [30,31].It is possible the observed results of female involvement in orthopaedic research consortiums are inherently skewed, as members of these research consortiums are also likely to be involved in academic practices and there is a greater percentage of women in academic positions compared to general orthopaedic practice.
Considering the percentage of women serving as lead authors in the studies produced by consortiums (23%), female surgeons are not only achieving higher levels of representation within research groups, but they are also more frequently functioning in primary roles for these collaborative research projects.It should be noted that women accounted for only 11% of senior authors of studies.These results are not surprising, given the traditional progressions in authorship observed over the course of an academic career.It is likely that as women become more involved in these collaborative efforts (particularly in leadership roles), senior authorship may also increase with time.Hiller et al., in a review of leading orthopaedic journals over a 12year period (2006-2017), reported that women were lead authors in 13% of articles and senior authors in 10% of articles [8].Recent studies suggest females comprise only 16% of orthopaedic surgery residents, 4% of American Academy of Orthopaedic Surgery fellows and 6% of practising orthopaedic surgeons [7,11,[32][33][34].Our results suggest female authorship, and involvement in orthopaedic research consortiums appears to be greater than in the overall orthopaedic literature and general practice.
When examining the membership of URMs in orthopaedic research consortiums, this study found they comprised 368 (16.3%) members.This representation is similar to several orthopaedic professional societies [7,26].However, this is a smaller percentage than what is reported in academic orthopaedics based on a recent study that investigated the demographic make-up within the board of directors, editorial boards, National Institute of Health (NIH) grant recipients and accreditation boards [35].We found 24.5% of lead authors to be URMs, which appears favourable considering that this population comprised only 16.3% of members of the consortiums.URM authors were also well represented in terms of senior authorship, comprising 17.2% of senior authors in this study.It is unknown how these trends compare to general orthopaedic practice and research independent of research consortiums.
As stated previously, spine was by far the most common topic published by these orthopaedic research consortiums with about 40% of all publications being spine-related topics.Over twice as much as the next most common topics of trauma (n=41, 15.7%) and adult reconstruction (n=27, 10.3%).However, it is not completely clear to the authors why this was observed, as there is no prior research to the authors' knowledge to suggest this.However, the authors can speculate that spine may have had more involvement due to many of the topics in spine overlapping other subspecialties of orthopaedics, in particular paediatrics, which was found to be the most common fellowship training of orthopaedic surgeons in consortiums.For example, many of the spine-related articles focused on scoliosis, as well as other paediatric syndromes with spine manifestations.
Peer-reviewed publications produced by modern orthopaedic research groups and consortiums exist in all orthopaedic subspecialities.The majority (87%) of these groups were collaborative, multi-centre efforts with a median of 18 members.In general, orthopaedic research consortiums appear to be publishing studies with higher LOE compared to levels noted in prior bibliometric studies of orthopaedic literature.The average LOE in orthopaedic research has historically been poor, with only 0.8% of articles published by 2002 and 4.1% by 2012 containing level I evidence [36].We found 12.6% of identified investigations produced by research consortiums contained level I evidence and over 76% of studies contained at least level III evidence.Several prior studies have shown that level IV evidence comprised between 43% and 63% of their bibliometric analyses of orthopaedic studies [36][37][38].A more recent study of orthopaedic literature from 2013 to 2018 found an increase in the mean level of evidence and suggested that level III evidence has become more prevalent, while the frequency of high-level studies (defined as level I or level II evidence) decreased over the same time period [39].Conducting large clinical trials with appropriate sample sizes and study power may require collaboration and multi-centre involvement.These investigations can be logistically difficult, and many prospective clinical trials are terminated prior to completion [40].In this context, research consortiums may be ideal avenues to design and implement these challenging clinical investigations.

Limitations
This study has several limitations.We utilized a three-year period for identifying research consortiums.Although this was done to exclude inactive consortiums that have not published recently, it is possible that we missed active groups that publish infrequently.In addition, we included a variety of journals; however, it is possible that there were consortiums that published in journals that were not included.We were unable to identify members for 15 groups (16.3%) and it is uncertain how the demographics of unidentified members would have impacted our results.We elected to define race and sex in binary terms by searching the internet based on previous methodologies; however, this type of classification is not without limitations.For example, we were unable to determine the sex of 114 (5%) researchers and unable to determine the race of 198 (8.8%) researchers.As a final limitation, our definition of URMs is based on the racial breakdown in the US and, therefore, may not be applicable to other nations.
following: Payment/services info: All authors have declared that no financial support was received from any organization for the submitted work.Financial relationships: All authors have declared that they have no financial relationships at present or within the previous three years with any organizations that might have an interest in the submitted work.Other relationships: All authors have declared that there are no other relationships or activities that could appear to have influenced the submitted work. .
Dutch Clinical Spine Research Group EF3X-trial Study Group ESCMID Study Group for Implant-Associated Infections (ESGIAI) Exeter Hip Group 2024 Ozdag et al.Cureus 16(3): e55859.DOI 10.7759/cureus.558594 of 13 FACTS (Function After Adolescent Clavicle Trauma and Surgery) Study Group FISH Investigators Fracture-related Infection (FRI) Consensus Group Global Fragility Fracture Network Hip Fracture Audit Special Interest Group PRONOMOS Investigators 2024 Ozdag et al.Cureus 16(3): e55859.DOI 10.7759/cureus.558595 of 13 REGAIN Investigators Regional Prosthetic Joint Infection Working Group Revision Knee Replacement Priority Setting Partnership Steering Group ROCK (Research in OsteoChondritis Dissecans of the Knee) Group

TABLE 2 : List of all the identified research consortiums A
list of members was identified for 77 groups (83.7%).In total, 2,260 researchers were identified.Most researchers were male (n=1,748, 77.3%) and white (n=1,694, 75%).Orthopaedic surgeons comprised 1,613 (71.4%) identified researchers.Fellowship training for orthopaedic surgeons was widely distributed with no single group comprising a substantial percentage.Fellowship information of the identified surgeons is displayed in Table3.