The Competitiveness of Orthopaedic Surgery Residency Programs: A Twenty-year Analysis Utilizing a Normalized Competitive Index

Objective: To apply a normalized competitive index over a 20-year period to analyse applicant trends in ortho-paedic surgery residency programs. Design: A retrospective analysis of orthopaedic surgery residency program data from the National Resident Matching Program (NRMP) Main Residency Match data from 2003 to 2022 and NRMP Charting Outcomes data from 2007 to 2021 was performed. A competitive index (CI) was utilized by dividing the number of programs ranked per applicant, multiplied by available positions, and by the match rate for each year. Next, the index was normalized to a value of 1 to establish a normalized competitive index (NCI) by dividing the yearly CI by the average CI.Setting: National Resident Matching Program (NRMP) Main Residency Match data from 1992 to 2021 and NRMP Charting Outcomes data from 2007 to 2021.Participants: Orthopaedic surgery residency applicants.Results: The NCI was significantly different over time (R-2= 0.95, p < 0.001) with an upward trending NCI slope. Total applicants have nearly doubled over the past two decades (2003, 830 vs. 2022, 1460; p<0.001). The match rate did not significantly change over the two decades (2003-2012 vs. 2013-2022; 70% vs. 70%; p = 0.76). However, in 2022, the match rate dropped to 59.5%. The 2022 applicant cycle had 14% more applicants, while positions increased by 0.8% compared to the year prior. The USMLE Step 1 and Step 2 scores of matched applicants increased over time (R2>0.83, p < 0.001). Research output quadrupled over the 2007-2021 period (3 vs. 14, p < 0.001).Conclusion: Despite match rates remaining constant over time, the NCI metric demonstrated the increasing competitiveness of orthopaedic surgery residency programs over twenty years. Match rates have inherent lim-itations as a singular metric and should only be used in conjunction with additional metrics. Establishing a more comprehensive index with applicant metrics provides insight into the growing competitiveness of orthopaedic programs and a more comprehensive outlook for future applicants.