Clinical Orthopaedics and Related Research ®

A Publication of The Association of Bone and Joint Surgeons ®

Published in
Clinical Orthopaedics and Related Research®
Volume 469 | Issue 7 | Jul, 2011

Keynote Address: The Need for Greater Racial and Ethnic Diversity in Orthopaedic Surgery

Louis W. Sullivan MD, Ilana S. Mittman PhD

Advances in medicine in the past century have resulted in substantial reductions in morbidity and mortality in the United States. However, despite these improvements, ethnic and racial minorities continue to experience health status and healthcare disparities. There is inadequate national awareness of musculoskeletal health disparities, which results in greater chronic pain and disability for members of ethnic and racial minority groups. The Sullivan Commission concluded in 2004 the inability of the health professions to keep pace with the US population is a greater contributor to health disparities than lack of insurance.

Culturally Competent Care Pedagogy: What Works?

Daryll C. Dykes MD, PhD, Augustus A. White MD, PhD

In its 2002 publication, the Institute of Medicine reported American racial and ethnic minorities receive lower-quality health care than white Americans. Because caregiver bias may contribute to disparate health care, the Liaison Committee on Medical Education and the Accreditation Council for Graduate Medical Education have issued specific directives to address culturally competent care education.

Defining Racial and Ethnic Disparities in THA and TKA

Kaan Irgit MD, Charles L. Nelson MD

For minority populations in the United States, especially African Americans, Hispanics, and Native Americans, healthcare disparities are a serious problem. The literature documents racial and ethnic utilization disparities with regard to THA and TKA.

Examining Sex and Gender Disparities in Total Joint Arthroplasty

Wendy M. Novicoff PhD, Khaled J. Saleh MD, MSc, MHCM

Total joint arthroplasty (TJA) is remarkably successful for treating osteoarthritis: most patients see substantial gains in function. However, there are considerable geographic, racial, and gender variations in the utilization of these procedures. The reasons for these differences are complex.

Patient Gender Affects the Referral and Recommendation for Total Joint Arthroplasty

Cornelia M. Borkhoff PhD, Gillian A. Hawker MD, MSc, FRCPC, James G. Wright MD, MPH, FRCSC

Rates of use of total joint arthroplasty among appropriate and willing candidates are lower in women than in men. A number of factors may explain this gender disparity, including patients’ preferences for surgery, gender bias influencing physicians’ clinical decision-making, and the patient-physician interaction.

Ethnic and Racial Factors Influencing Well-being, Perceived Pain, and Physical Function After Primary Total Joint Arthroplasty

Carlos J. Lavernia MD, Jose C. Alcerro MD, Juan S. Contreras MD, Mark D. Rossi PhD

Studies suggest, even when controlling for disease severity, socioeconomic status, education, and access to care, racial and ethnic minorities receive lower-quality health care and have worse perceived pain and function before and after total joint arthroplasty.

Implant Survival, Knee Function, and Pain Relief After TKA: Are There Differences Between Men and Women?

Mary I. O’Connor MD

As efforts continue to improve the results of TKA, the potential influence of sex and gender on long-term survival of implants, knee function, pain relief, and patient satisfaction remains relevant, particularly given the increased incidence of osteoarthritis of the knee in women and reports that women derive equal benefit from TKA.

Do We Need Gender-specific Total Joint Arthroplasty?

Aaron J. Johnson MD, Christopher R. Costa MD, Michael A. Mont MD

Gender-specific differences in knee and hip anatomy have been well documented. Although it has been accepted these differences exist, there is controversy regarding if and how these differences should be addressed with gender-specific implant designs.

Defining Racial and Ethnic Disparities in Pain Management

Jana M. Mossey PhD, MPH, MSN

Substantial pain prevalence is as high as 40% in community populations. There is consistent evidence that racial/ethnic minority individuals are overrepresented among those who experience such pain and whose pain management is inadequate.

Defining Gender Disparities in Pain Management

Linda LeResche ScD

Prevalence rates of most musculoskeletal pain conditions are higher among women than men. Reasons for these prevalence disparities likely include sex differences in basic pain mechanisms and gender differences in psychosocial factors.

Breakout Session: Diversity, Cultural Competence, and Patient Trust

Christopher J. Dy MD, MSPH, Charles L. Nelson MD

The patient population served by orthopaedic surgeons is becoming increasingly more diverse, but this is not yet reflected in our workforce. As the cultural diversity of our patient population grows, we must be adept at communicating with patients of all backgrounds.

Breakout Session: Gender Disparities in Knee Osteoarthritis and TKA

Mary I. O’Connor MD, Elizabeth Gerken Hooten ScD, MSPH, CPH

Biologically derived (sex-based) and behaviorally influenced (gender-based) disparities exist in knee osteoarthritis and treatment with TKA.

Breakout Session: Ethnic and Racial Disparities in Joint Arthroplasty

Randall C. Morgan MD, MBA, James Slover MD, MS

Many authors report racial and ethnic disparities in total joint arthroplasty. The extent and implications, however, are not fully understood.

Defining Ethnic and Racial Differences in Osteoporosis and Fragility Fractures

Jane A. Cauley DrPH

Osteoporotic fractures are a major public health issue. The literature suggests there are variations in occurrence of fractures by ethnicity and race.

Gender Differences in Osteoporosis and Fractures

Peggy M. Cawthon PhD, MPH

Osteoporosis is generally thought of as a “woman’s disease” because the prevalence of osteoporosis and the rate of fractures are much higher in postmenopausal women than in older men. However, the absolute number of men affected by osteoporosis and fractures is large, as at least 2.8 million men in the United States are thought to have osteoporosis.

Sex and Gender Considerations in Male Patients With Osteoporosis

Christopher J. Dy MD, MSPH, Lauren E. LaMont MD, Quang V. Ton MD, Joseph M. Lane MD

Osteoporosis remains underrecognized and undertreated in both men and women, but men who sustain fragility fractures experience greater morbidity and mortality. While men exhibit advanced comorbidity at the time of hip fracture presentation, there are distinct sex- and gender-specific factors related to the pathophysiology and treatment of osteoporosis that further influence morbidity and mortality.

Gender and Race/Ethnicity Differences in Hip Fracture Incidence, Morbidity, Mortality, and Function

Robert S. Sterling

Hip fracture is an international public health problem. Worldwide, approximately 1.5 million hip fractures occur per year, with roughly 340,000 in the United States in individuals older than 65 years. In 2050, there will be an estimated 3.9 million fractures worldwide, with more than 700,000 in the United States. However, whether there are disparities in morbidity, mortality, and function between men and women or between races/ethnicities is unclear.

Does a Multidisciplinary Team Decrease Complications in Male Patients With Hip Fractures?

Christopher J. Dy MD, MSPH, Paul-Michel Dossous MPH, Quang V. Ton MD, James P. Hollenberg MD, Dean G. Lorich MD, Joseph M. Lane MD

Men with hip fractures are more likely to experience postoperative complications than women. The Medical Orthopaedic Trauma Service program at New York Presbyterian Hospital utilizes a multidisciplinary team approach to care for patients with hip fractures. The service is comanaged by an attending hospitalist and orthopaedic surgeon, with daily walking rounds attended by the hospitalist, orthopaedic resident, physical therapist, social worker, and a dedicated Medical Orthopaedic Trauma Service physician assistant.

Optimizing Screening for Osteoporosis in Patients With Fragility Hip Fracture

Archana Roy MD, Michael G. Heckman MSc, Mary I. O’Connor MD

Osteoporosis, the underlying cause of most hip fractures, is underdiagnosed and undertreated. The 2008 Joint Commission reportshowed only an average of 20% of patients with low-impact fracture are ever tested or treated for osteoporosis. We developed an integrated model utilizing hospitalists and orthopaedic surgeons to improve care of osteoporosis in patients with hip fracture.

Minimizing Disparities in Osteoporosis Care of Minorities With an Electronic Medical Record Care Plan

Ronald A. Navarro MD, Denise F. Greene RNP, Raoul Burchette MS, Tadashi Funahashi MD, Richard Dell MD

Ethnic disparities in care have been documented with a number of musculoskeletal disorders including osteoporosis. We suggest a systems approach for ensuring osteoporosis care can minimize potential ethnic disparities in care.

Breakout Session: Sex/Gender and Racial/Ethnic Disparities in the Care of Osteoporosis and Fragility Fractures

Mark D. Neuman MD, Ann M. Kennelly BA, Laura L. Tosi MD

Recent epidemiologic and clinical data suggest men and racial and ethnic minorities may receive lower-quality care for osteoporosis and fragility fractures than female and nonminority patients. The causes of such differences and optimal strategies for their reduction are unknown.

Disparities in Amputations in Minorities

Kristin M. Lefebvre PT, PhD, CCS, Lawrence A. Lavery DPM, MPH

As a result of the impact of health disparities on the healthcare system such as their influence on arenas significant to healthcare distribution, including cost, quality, and access, identification and resolution of health disparities is a primary national agenda item. Resolution of disparities in amputation is an area of opportunity that warrants further consideration.

Gender Differences in Diabetes-related Lower Extremity Amputations

Monica E. Peek MD, MPH

Diabetes is a major cause of morbidity and mortality in the United States, with much of the economic and social costs related to macrovascular and microvascular complications, such as myocardial infarctions, renal failure, and lower extremity amputations. While racial/ethnic differences in diabetes are well documented, less attention has been given to differences in diabetes outcomes by gender.

Mortality in Female War Veterans of Operations Enduring Freedom and Iraqi Freedom

Jessica D. Cross MD, Anthony E. Johnson MD, Joseph C. Wenke PhD, Michael J. Bosse MD, James R. Ficke MD

Combat-wounded service members are surviving battle injuries more than ever. Given different combat roles held by men and women, female service members should survive wounds at an unprecedented rate.

Breakout Session: Gender and Ethnic Disparities in Pain Management

Atul F. Kamath MD, Mary I. O’Connor MD

Pain management is a complex and evolving topic. Treatment of pain must account for biochemical as well as social and economic factors. Sex, gender, and ethnic differences exist in the pathophysiology, diagnosis, and provision of care for patients with pain.

Breakout Session: Ethnic and Gender Differences in Diabetic Foot Management and Amputations

Anthony E. Johnson MD, Carlos Lavernia MD

Although the health status of all Americans has improved substantially in the past century, gender and ethnic disparities still persist. Gender and ethnic disparities in diabetic foot management and amputations are an important but largely ignored issue in musculoskeletal health care.

Is Total Hip Arthroplasty after Hip Arthrodesis as Good as Primary Arthroplasty?

Mariano Fernandez-Fairen PhD, MD, Antonio Murcia-Mazón PhD, MD, Ana Torres MD, Virginia Querales MD, Antonio Murcia MD

Conversion of hip arthrodesis to a THA reportedly provides a reasonable solution, improving function, reducing back and knee pain, and slowing degeneration of neighboring joints associated with a hip fusion. Patients generally are satisfied with conversion despite the fact that range of mobility, muscle strength, leg-length discrepancy (LLD), persistence of limp, and need for assistive walking aids generally are worse than those for conventional primary THA.

Does Trochanteric Transfer Eliminate the Trendelenburg Sign in Adults?

Flávio L. Garcia MD, PhD, Celso H. F. Picado MD, PhD, Luís P. Cardinali MD

Premature closure of the proximal femoral growth plate results in coxa brevis, which usually is associated with insufficiency of the hip abductors. Distal and lateral transfer of the greater trochanter sometimes is recommended to correct this problem. Most of what is known arises from studies of children and adolescents.

Does High Tibial Osteotomy Affect the Success or Survival of a Total Knee Replacement?

John B. Meding MD, Jennifer T. Wing, Merrill A. Ritter MD

Whether a previous high tibial osteotomy (HTO) influences the long-term function or survival of a total knee arthroplasty (TKA) is controversial.

Does Tranexamic Acid Save Blood in Minimally Invasive Total Knee Arthroplasty?

Po-Chun Lin MD, Chi-Hsiang Hsu MD, Wun-Schen Chen MD, Jun-Wen Wang MD

Tranexamic acid (TEA) reportedly reduces perioperative blood loss in TKA. However, whether it does so in minimally invasive TKA is not clear.

Distal Femoral Osteotomy: Is Internal Fixation Better than External?

K. T. Matthew Seah BMedSci, MBChB, Raheel Shafi MD, Austin T. Fragomen MD, S. Robert Rozbruch MD

Distal femoral osteotomies (DFO) can be used to correct deformities around the knee. Although osteotomies can be fixed with either internal or external fixation techniques, the advantages of one over the other are unclear.

Ischial Spine Sign Reveals Acetabular Retroversion in Legg-Calvé-Perthes Disease

A. Noelle Larson MD, Anthony A. Stans MD, Rafael J. Sierra MD

Acetabular retroversion has been identified in mature patients with sequelae of Legg-Calvé-Perthes (LCP) disease. Whether this is a contributing etiologic factor that leads to the disease process or result of the head deformity is not known. The prominence of the ischial spine (PRIS) sign, which reflects retroversion, can be observed before ossification of the anterior and posterior walls in a skeletally immature patient and could help determine whether the retroverted acetabulum is present before or after head involvement in patients with LCP disease.

Bizarre Parosteal Osteochondromatous Proliferation: A Locally Aggressive Benign Tumor

Jibu Joseph MRCS, David Ritchie FRCR, Elaine MacDuff FRCPath, Ashish Mahendra FRCS (Trauma & Orth)

Bizarre parosteal osteochondromatous proliferation (BPOP) is a benign lesion of bone, and numerous questions remain unresolved regarding its etiology, diagnosis, and treatment.

Nonoperative versus Prophylactic Treatment of Bisphosphonate-associated Femoral Stress Fractures

Michael B. Banffy MD, Mark S. Vrahas MD, John E. Ready MD, John A. Abraham MD

Several studies have identified a specific fracture in the proximal diaphysis of the femur in patients treated with bisphosphonates. The fractures typically are sustained after a low-energy mechanism with the presence of an existing characteristic stress fracture. However, it is unclear whether these patients are best treated nonoperatively or operatively.

Can Computed Tomography Predict Hip Stability in Posterior Wall Acetabular Fractures?

Jeffrey M. Reagan MD, Berton R. Moed MD

In a pilot study, two-dimensional (2-D) CT assessment of posterior wall fracture fragments predicted hip stability with small fracture fragments and instability for large fracture fragments.

Smartphone Apps for Orthopaedic Surgeons

Orrin I. Franko MD

The use of smartphones and their associated applications (apps) provides new opportunities for physicians, and specifically orthopaedic surgeons, to integrate technology into clinical practice.

Orthopaedic Web Links (OWL): A Way to Find Professional Orthopaedic Information on the Internet

J. F. M. Clough MD, DPhil, FRCS(C), C. J. H. Veillette MD, MSc, FRCS(C)

Finding useful high-grade professional orthopaedic information on the Internet is often difficult. Orthopaedic Web Links (OWL) is a searchable database of vetted online orthopaedic resources. OWL uses a subject directory (OWL Directory) and a custom search engine (OWL Web) to provide a list of resources. The most effective way to find readily accessible, full text on-subject material suitable for education of an orthopaedic surgeon or trainee has not been defined.

Rheumatoid Synovectomy: Does the Surgical Approach Matter?

Peter N. Chalmers MD, Seth L. Sherman MD, Bradley S. Raphael MD, Edwin P. Su MD

Surgical synovectomy relieves pain in patients with rheumatoid arthritis (RA). The comparative effect of arthroscopic versus open synovectomy on pain reduction, recurrence of synovitis, radiographic progression, and need for subsequent total joint arthroplasty (TJA) is unclear. Whether synovectomy relieves pain in patients with advanced degenerative joint changes is also controversial.

Case Report: Lower Extremity Sparganosis in a Bursa

Kee-Yong Ha MD, In-Soo Oh MD

Sparganosis is a rare parasitic infection caused by the plerocercoid tapeworm larva of the genus Spirometra.

Emerging Ideas: Shared Decision Making in Patients with Osteoarthritis of the Hip and Knee

Kevin J. Bozic MD, MBA, Vanessa Chiu MPH

Despite the widely reported success of total joint arthroplasty (TJA) in reducing pain and improving quality of life and function for patients with hip or knee osteoarthritis, rates of TJA use vary widely throughout the United States, with broad disparities based on geographic, racial, and socioeconomic factors. Shared decision-making approaches, which require an exchange of information between patients and their physicians, can be helpful in improving patient satisfaction with their treatment decision and appropriate use of TJA.

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