Patient gender may influence the referral and recommendation process for total joint arthroplasty.
Courtesy of Cornelia Borkhoff, PhD


Published 7/1/2010
Jennie McKee

Closing the TJA gender gap

Gender disparities in total joint arthroplasty

Two patients—one male, one female, both with osteoarthritis of the knee and with identical clinical scenarios of chronic knee pain—visit their primary care provider. The man is referred to an orthopaedist for a possible arthroplasty. The woman is given prescriptions for an analgesic and physiotherapy. Is this appropriate care—or does it demonstrate a gender disparity?

“Although age-adjusted rates of total joint arthroplasty (TJA) are higher for women than men, a Canadian population-based study found that underuse of TJA among willing and appropriate candidates is more than 3 times greater in women than men,” said Cornelia Borkhoff, PhD, of the Canadian Osteoarthritis Research Program at Women’s College Hospital in Toronto, Canada. Dr. Borkhoff was a featured speaker at the recent AAOS/Orthopaedic Research Society/American Bone and Joint Surgeons sponsored research symposium on Musculoskeletal Health Care Disparities.

What’s at the root of this disparity? Dr. Borkhoff believes that the answer may lie in subtle or overt bias and other factors related to a patient’s gender.

According to Dr. Borkhoff, patients go through eight steps from the initial recognition that something is wrong until the final decision to have surgery (Fig. 1). At any point along the way, the patient’s gender may play a role in healthcare decisions.

Primary care “gatekeepers”
The first step occurs when patients recognize they have a treatable medical condition, said Dr. Borkhoff.

“Women have been shown to be at least as willing as men to consider TJA, and women are more likely than men to seek treatment for osteoarthritis and other medical conditions,” said Dr. Borkhoff. “Thus, gender does not appear to have an important influence on this step.”

At the second step in the process, the patient obtains access to a healthcare provider. Although access to health care is frequently cited as a possible explanation for disparities based on race, access barriers are less relevant for gender disparities.

“Most people in the United States who have advanced osteoarthritis are 65 years or older and are therefore eligible for Medicare,” she said. “In Canada, patients of all ages have universal access to health care. So, it would appear that women’s access to health care is comparable to that of men.”

In step 3, the patient reports symptoms, and in step 4, the primary care physician, who acts as a “gatekeeper,” determines whether to refer the patient to an orthopaedic surgeon. Dr. Borkhoff noted that many primary care physicians lack sufficient musculoskeletal training and are therefore inconsistent about the level of pain and disability that warrants TJA.

“Primary care physicians also tend to overestimate the risks and underestimate the benefits of arthroplasty,” she said. “This is not surprising, because no guidelines currently exist, other than expert consensus reports, regarding which patients should be considered for TJA.”

Research indicates that primary care physicians refer women less often or later for specialty care.

“Primary care physicians do not refer women for surgical consultation until the degree of disability has progressed to a relatively serious level,” said Dr. Borkhoff.

Communication issues
Another factor that may affect a physician’s referral patterns is the way patients describe their symptoms.

“Women speak more openly and personally about their symptoms, describing them in a narrative style,” said Dr. Borkhoff. “As a result, the physician may perceive the woman as being reluctant to have surgery.”

Men may be perceived as more willing to undergo surgery, she said, “because they typically pre-sent their symptoms in a businesslike, factual manner.”

In step 5, the patient either accepts or does not accept the primary care physician’s treatment recommendation. The patient’s perception of the severity of his or her arthritis plays a significant role in this decision.

“There’s some evidence that women may perceive their arthritis to be less severe than men do,” she said.

Dr. Borkhoff also noted that female patients tend to receive less information about TJA than male patients. To illustrate this point, Dr. Borkhoff referred to the study she and her colleagues, including Gillian A. Hawker, MD, MSc; James G. Wright, MD, MPH; and Hans J. Kreder, MD MPH, conducted from August 2003 to October 2005 using two standardized patients—one male and one female patient with chronic, moderate knee osteoarthritis—who visited 71 physicians, including 38 family physicians and 33 orthopaedic surgeons.

“In our standardized patient study, we found that physicians were less likely to discuss the clinical issues of the decision, such as how long the hospital stay would be, with the female patient than with the male patient,” said Dr. Borkhoff. “Physicians seldom discussed the female patient’s role in the decision, assessed her understanding of the decision, or assessed her treatment preferences. As a result, the female patient had less information and less encouragement to participate in the decision to undergo TJA.

“We know that patients who get less information and less encouragement to participate in decision-making are less satisfied and are less likely to accept physicians’ treatment recommendations,” she added.

Referral to an orthopaedist
At step 6, the patient reports symptoms of chronic knee pain or hip pain to the orthopaedist, who determines whether the patient is a candidate for surgery.

“Based on the Canadian population-based study, among appropriate candidates for surgery, women were less likely than men to report having discussed TJA with an orthopaedist,” said Dr. Borkhoff. “Women are therefore less likely than men to reach this step.”

Orthopaedists—just like primary care physicians—may interpret the female’s communication style as expressing reluctance to undergo TJA.

“An orthopaedic surgeon who senses any reservation from a patient is not likely to consider that patient a good surgical candidate,” noted Dr. Borkhoff. “Subtle or overt gender bias may also inappropriately influence orthopaedists’ clinical decision-making.

“In our study, 93 percent of the orthopaedists recommended TJA to the man, but only 38 percent recommended it to the woman,” she said. “The orthopaedic surgeon recommended TJA to the male patient 22 times more often than to the female patient.”

After a recommendation is made, the final step occurs—the patient either proceeds with or rejects the recommended surgery.

“In the Canadian population-based cohort, 9 percent of men and 13 percent of women were definitely willing to consider TJA,” said Dr. Borkhoff. “Despite the relatively equal willingness to have surgery, the most important predictor of definite willingness was having previously discussed TJA with a physician, and women are less likely to have done so.”

Other factors may keep women from accepting an orthopaedist’s recommendation for surgery. Research has shown, said Dr. Borkhoff, that women perceive the risks of TJA to be higher than men do. In addition, compared to men, women are more concerned that the surgery will interfere with their caregiving roles and that they will be a burden on others during recovery.

Bridging the divide
According to Dr. Borkhoff, interventions to address the disparity in TJA usage among women are needed.

“Primary care physicians need tools to assist them in making decisions about referral for orthopaedic consultation,” she said.

In addition, Dr. Borkhoff noted physicians need to improve their shared decision-making skills and must receive more training in delivering culturally competent care.

“Good-quality decision aids focused on hip and knee osteoarthritis treatment, such as online resources, brochures, and DVDs, may improve patients’ informed decision-making and willingness to have TJA,” she asserted. “Decision aids are designed to help patients make an informed choice between two or more equally relevant treatment options. When patients arrive at their surgical consultation prepared and informed, the surgeon can focus on issues of concern to the individual patient, leading to a more efficient clinical encounter and care that is more patient-centered.”

Dr. Borkhoff and colleagues plan to perform a study to evaluate the effect of “patient preference reports,” resources that clearly specify the severity of the patient’s condition, that can be included as part of patient decision aids for hip and knee osteoarthritis treatment.

In addition, mass media campaigns may help the general public, healthcare providers, and patients learn about the indications for and expected outcomes of TJA and the potential benefits of early treatment.

“Even though the prevalence and severity of osteoarthritis disproportionately affects disadvantaged populations, few studies evaluate the effectiveness of interventions to improve healthcare quality in these populations,” said Dr. Borkhoff. “Studies evaluating interventions that target healthcare providers, such as shared decision-making skills or decision support tools, are also lacking.

“It’s time to evaluate whether potential interventions are effective in reducing disparities in access to care, healthcare utilization, and healthcare outcomes of disadvantaged populations with osteoarthritis,” she said.

Disclosure information: Dr. Borkhoff— Canadian Institutes of Health Research Postdoctoral Fellowship Award. References for studies cited in this article are available in the online version at

Jennie McKee is a staff writer for AAOS Now. She can be reached at

Bottom line

  • Even though women are just as likely as men to seek treatment for osteoarthritis, physicians are less likely to recommend total joint arthroplasty (TJA) to a woman than to a man.
  • How physicians respond to male and female patients during the referral and recommendation process may affect a woman’s odds of undergoing TJA.
  • More training for physicians in culturally competent care and shared decision-making may reduce this disparity.

Symposium explores disparities
This spring, the AAOS, Orthopaedic Research Society (ORS), and the Association of Bone and Joint Surgeons (ABJS) hosted the first research symposium focused exclusively on examining disparities in musculoskeletal health care. Dr. Borkhoff was one of many participants at the AAOS/ORS/ABJS Musculoskeletal Healthcare Disparities Research Symposium, held May 6–7, 2010, in Alexandria, Va.

Mary O’Connor, MD; Charles Nelson, MD; and Carlos Lavernia, MD, co-chaired the symposium, which focused on defining and outlining gender and ethnic musculoskeletal healthcare disparities related to total joint arthroplasty, pain management, diabetic foot management, and amputation, as well as osteoporosis and fragility fractures.

Clinicians and researchers from various backgrounds identified potential solutions to disparities and explored relevant performance measures. The results of the symposium will be published in a supplement to Clinical Orthopaedics and Related Research.


  1. Borkhoff CM, Hawker GA, Kreder HJ, Glazier RH, Mahomed NN, Wright JG: The effect of patients’ sex on physicians’ recommendations for total knee arthroplasty. CMAJ, 2008;178(6):681-687.
  2. Hawker GA, Wright JG, Coyte PC, et al: Differences between men and women in the rate of use of hip and knee arthroplasty. N Engl J Med, 2000;342(14):1016-1022.
  3. Stacey D, Hawker G, Dervin G, et al: Management of chronic pain: Improving shared decision making in osteoarthritis. BMJ, 2008;336:954-955.